Provider Demographics
NPI:1629208475
Name:DAKE, TESSA KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:TESSA
Middle Name:KATHLEEN
Last Name:DAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-790-3697
Mailing Address - Fax:989-583-1742
Practice Address - Street 1:2429 TRAUTNER DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9596
Practice Address - Country:US
Practice Address - Phone:989-790-3697
Practice Address - Fax:989-583-1742
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100157207Q00000X
AZR71705207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR71705Medicaid