Provider Demographics
NPI:1497844377
Name:BAUER, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 N. ROANOKE
Mailing Address - Street 2:PO BOX 52
Mailing Address - City:HINES
Mailing Address - State:OR
Mailing Address - Zip Code:97738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1408
Practice Address - Country:US
Practice Address - Phone:541-573-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD82821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR229011Medicaid