Provider Demographics
NPI:1124227228
Name:DRAKE, CARL THOMAS (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:THOMAS
Last Name:DRAKE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SUSAN DRIVE, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-808-0054
Mailing Address - Fax:
Practice Address - Street 1:310 SUSAN DR
Practice Address - Street 2:STE 1
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6206
Practice Address - Country:US
Practice Address - Phone:309-808-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027428122300000X
IL021.0023681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics