Provider Demographics
NPI:1144619180
Name:BAEK DENTAL GROUP
Entity Type:Organization
Organization Name:BAEK DENTAL GROUP
Other - Org Name:RYAN BAEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AERI (KATIE)
Authorized Official - Middle Name:
Authorized Official - Last Name:BAEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-643-0300
Mailing Address - Street 1:428 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-3413
Mailing Address - Country:US
Mailing Address - Phone:215-643-0300
Mailing Address - Fax:215-643-0333
Practice Address - Street 1:428 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3413
Practice Address - Country:US
Practice Address - Phone:215-643-0300
Practice Address - Fax:215-643-0333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RYAN BAEK DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101930230Medicaid