Healthcare Provider Details

I. General information

NPI: 1730300344
Provider Name (Legal Business Name): TIMOTHY MAURICE DRAKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WEST 12TH AVENUE
MITCHELL SD
57301-1311
US

IV. Provider business mailing address

103 WEST 12TH AVENUE
MITCHELL SD
57301-1311
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-9235
  • Fax: 605-996-2080
Mailing address:
  • Phone: 605-996-9235
  • Fax: 605-996-2080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM-581
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: