Provider Demographics
NPI:1215773924
Name:CHILDRESS, DRAKE (DMD)
Entity type:Individual
Prefix:DR
First Name:DRAKE
Middle Name:
Last Name:CHILDRESS
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 1:114 CALUMET CENTER RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-6703
Mailing Address - Country:US
Mailing Address - Phone:706-882-1888
Mailing Address - Fax:
Practice Address - Street 1:114 CALUMET CENTER RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-6703
Practice Address - Country:US
Practice Address - Phone:706-882-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist