Provider Demographics
NPI:1376078279
Name:BAKER, BLAINE (DDS)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:BAKER
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 1:2900 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-8626
Mailing Address - Country:US
Mailing Address - Phone:406-656-6100
Mailing Address - Fax:406-656-8726
Practice Address - Street 1:2900 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-8626
Practice Address - Country:US
Practice Address - Phone:406-656-6100
Practice Address - Fax:406-656-8726
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MT153091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program