Provider Demographics
NPI:1417179300
Name:BAUER, BRENT ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ALAN
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 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:8600 BATAAN MEMORIAL E
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-6016
Practice Address - Country:US
Practice Address - Phone:575-382-2112
Practice Address - Fax:575-382-5064
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD52811223G0001X
AZD053521223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0306230OtherBCBSAZ PROVIDER #
AZ686355Medicaid