Provider Demographics
NPI:1356506596
Name:BAUER, KENNETH JAMES (DDS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JAMES
Last Name:BAUER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA346681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice