Provider Demographics
NPI:1245381920
Name:BRIAN P. BAKER DMD,PA
Entity Type:Organization
Organization Name:BRIAN P. BAKER DMD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-267-7072
Mailing Address - Street 1:1625 S WASHINGTON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4734
Mailing Address - Country:US
Mailing Address - Phone:321-267-7072
Mailing Address - Fax:321-267-4948
Practice Address - Street 1:1625 S WASHINGTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4734
Practice Address - Country:US
Practice Address - Phone:321-267-7072
Practice Address - Fax:321-267-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0012861261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental