Healthcare Provider Details

I. General information

NPI: 1447260930
Provider Name (Legal Business Name): MARK L. DAKE DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 N KENTUCKY AVE
WEST PLAINS MO
65775-2089
US

IV. Provider business mailing address

181 N KENTUCKY AVE
WEST PLAINS MO
65775-2089
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 Number014271
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: