MEDICARE: DR. DEREK CHRISTOPHER FUNK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7702857-9921	UT
2	1223G0001X	General Practice Dentistry	31378	TX

General Provider Information

NPI Number	:	1558675512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEREK CHRISTOPHER FUNK D.D.S.

Provider Business Mailing Address
First Line	:	303 N MCKINNEY ST
Second Line	:	SUITE A
City	:	SWEENY
State	:	TX
Zip	:	77480
Country	:	US
Telephone Number	:	979-548-2184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1345 E 3900 S
Second Line	:	SUITE 108
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1474
Country	:	US
Telephone Number	:	801-274-3768
Fax Number	:	801-273-9768

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	06/30/2017

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Practice Location Address:

1345 E 3900 S , 108
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1235257056 — JONATHAN G CAMPBELL DDS
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1345 E 3900 S , #116
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1255595773 — DR. BRIAN G HOLMAN D.D.S.
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