Basic Information
| Provider Information | |||||||||
| NPI: | 1023018264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | LAURENCE | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3564 MEMORIAL SHOREWAY | ||||||||
| Address2: | |||||||||
| City: | MARBLEHEAD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434402366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197988027 | ||||||||
| FaxNumber: | 7197988027 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 BIRCHARD AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434202967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193348855 | ||||||||
| FaxNumber: | 4193348619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30016054 | OH | Y | Dental Providers | Dentist |
No ID Information.