Provider Demographics
NPI:1053496083
Name:BAKER, DWIGHT DOUGLAS (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:DOUGLAS
Last Name:BAKER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4366
Mailing Address - Country:US
Mailing Address - Phone:208-524-0644
Mailing Address - Fax:208-524-6100
Practice Address - Street 1:1900 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4366
Practice Address - Country:US
Practice Address - Phone:208-524-0644
Practice Address - Fax:208-524-6100
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1911-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics