Provider Demographics
NPI:1013574896
Name:PREBLE, DEREK R (DMD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:R
Last Name:PREBLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 S ROGER DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3847
Mailing Address - Country:US
Mailing Address - Phone:801-971-5881
Mailing Address - Fax:
Practice Address - Street 1:3875 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4145
Practice Address - Country:US
Practice Address - Phone:801-971-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5991972-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice