Provider Demographics
NPI:1730300344
Name:DRAKE, TIMOTHY MAURICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MAURICE
Last Name:DRAKE
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 1:103 WEST 12TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-1311
Mailing Address - Country:US
Mailing Address - Phone:605-996-9235
Mailing Address - Fax:605-996-2080
Practice Address - Street 1:103 WEST 12TH AVENUE
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1311
Practice Address - Country:US
Practice Address - Phone:605-996-9235
Practice Address - Fax:605-996-2080
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM-5811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice