Provider Demographics
NPI:1114650207
Name:KENNETH J. BAUER, DDS, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KENNETH J. BAUER, DDS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-799-1228
Mailing Address - Street 1:55 MISSION CIR STE 107
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-5372
Mailing Address - Country:US
Mailing Address - Phone:707-538-1086
Mailing Address - Fax:707-538-0934
Practice Address - Street 1:55 MISSION CIR STE 107
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-5372
Practice Address - Country:US
Practice Address - Phone:707-538-1086
Practice Address - Fax:707-538-0934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty