Provider Demographics
NPI:1437257599
Name:BAUMGARTNER, JERRY GEORGE (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:GEORGE
Last Name:BAUMGARTNER
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:S3740A WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665
Mailing Address - Country:US
Mailing Address - Phone:608-634-6933
Mailing Address - Fax:608-637-2298
Practice Address - Street 1:2724 BRAVE RIFLES REGIMENT RD
Practice Address - Street 2:HQ USA DENTAL ACTIVITY
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-6158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33486700Medicaid