Healthcare Provider Details

I. General information

NPI: 1346682184
Provider Name (Legal Business Name): MARK L. DAKE DDS, MSD AND DAVID SANDER DMD, MDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 N. KENTUCKY SUITE 300
WEST PLAINS MO
65775
US

IV. Provider business mailing address

181 N. KENTUCKY SUITE 300
WEST PLAINS MO
65775
US

V. Phone/Fax

Practice location:
  • Phone: 417-256-5100
  • Fax: 417-257-0721
Mailing address:
  • Phone: 417-256-5100
  • Fax: 417-257-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK DAKE
Title or Position: MEMBER
Credential: DDS, MSD
Phone: 417-256-5100