MEDICARE: DR. DARREL DUANE DREKE 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	5411	WA

General Provider Information

NPI Number	:	1669474714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARREL DUANE DREKE D.D.S.

Provider Business Mailing Address
First Line	:	22002 64TH AVE W
Second Line	:	STE 2A
City	:	MOUNTLAKE TERRACE
State	:	WA
Zip	:	98043-2547
Country	:	US
Telephone Number	:	425-771-3505
Fax Number	:	425-775-8328

Provider Business Practice Location Address
First Line	:	22002 64TH AVE W
Second Line	:	STE 2A
City	:	MOUNTLAKE TERRACE
State	:	WA
Zip	:	98043-2547
Country	:	US
Telephone Number	:	425-771-3505
Fax Number	:	425-775-8328

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/08/2007

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