Provider Demographics
NPI:1265742258
Name:BRAKE, DUSTIN JACOB (DC)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:JACOB
Last Name:BRAKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 WAKARUSA DR
Mailing Address - Street 2:APT G6
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-3353
Mailing Address - Country:US
Mailing Address - Phone:785-218-8539
Mailing Address - Fax:
Practice Address - Street 1:3120 MESA WAY
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4200
Practice Address - Country:US
Practice Address - Phone:785-842-7325
Practice Address - Fax:785-842-7329
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05351111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor