Provider Demographics
NPI:1508967639
Name:BAKER, LARRY L (MD, DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68902-0947
Mailing Address - Country:US
Mailing Address - Phone:402-463-3088
Mailing Address - Fax:402-463-3099
Practice Address - Street 1:501 W 9TH ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-3908
Practice Address - Country:US
Practice Address - Phone:402-463-3088
Practice Address - Fax:402-463-3099
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22775204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025150000Medicaid
NE099617Medicare ID - Type UnspecifiedPROFESSIONAL CORPORATION
NE10025150000Medicaid
NE278364Medicare ID - Type UnspecifiedINDIVIDUAL