Provider Demographics
NPI:1558675512
Name:FUNK, DEREK CHRISTOPHER (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:CHRISTOPHER
Last Name:FUNK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N MCKINNEY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SWEENY
Mailing Address - State:TX
Mailing Address - Zip Code:77480
Mailing Address - Country:US
Mailing Address - Phone:979-548-2184
Mailing Address - Fax:
Practice Address - Street 1:1345 E 3900 S
Practice Address - Street 2:SUITE 108
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1474
Practice Address - Country:US
Practice Address - Phone:801-274-3768
Practice Address - Fax:801-273-9768
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7702857-99211223G0001X
TX313781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice