Provider Demographics
NPI:1407211725
Name:BAKER PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:BAKER PEDIATRIC DENTISTRY, PLLC
Other - Org Name:BAKER PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CECIL
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-524-0644
Mailing Address - Street 1:1900 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-524-0644
Mailing Address - Fax:208-524-6100
Practice Address - Street 1:1900 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401
Practice Address - Country:US
Practice Address - Phone:208-524-0644
Practice Address - Fax:208-524-6100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID28510Medicaid