Provider Demographics
NPI:1376038687
Name:DAWSON, DEREK RAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:RAY
Last Name:DAWSON
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 1:309 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1315
Mailing Address - Country:US
Mailing Address - Phone:435-283-4081
Mailing Address - Fax:
Practice Address - Street 1:309 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1315
Practice Address - Country:US
Practice Address - Phone:435-283-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12978392-99221223G0001X
NV75971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice