Provider Demographics
NPI:1700993789
Name:DRAKE, BRIAN C (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:DRAKE
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 1:625 EAST 500 SOUTH
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-292-4111
Mailing Address - Fax:801-296-8030
Practice Address - Street 1:625 EAST 500 SOUTH
Practice Address - Street 2:SUITE 101
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-292-4111
Practice Address - Fax:801-296-8030
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1406359921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist