Provider Demographics
NPI:1093051344
Name:JASON E BAKER DDS LLC
Entity Type:Organization
Organization Name:JASON E BAKER DDS LLC
Other - Org Name:MIRAMAR BEACH DENTAL & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-650-2070
Mailing Address - Street 1:77 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-4967
Mailing Address - Country:US
Mailing Address - Phone:850-650-2070
Mailing Address - Fax:850-650-2073
Practice Address - Street 1:77 SOUTH SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550
Practice Address - Country:US
Practice Address - Phone:850-650-2070
Practice Address - Fax:850-650-2073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL177841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty