Provider Demographics
NPI:1558577841
Name:BAKER, MAC L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAC
Middle Name:L
Last Name:BAKER
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 1:440 HWY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2351
Mailing Address - Country:US
Mailing Address - Phone:601-833-7241
Mailing Address - Fax:601-833-3183
Practice Address - Street 1:440 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2351
Practice Address - Country:US
Practice Address - Phone:601-833-7241
Practice Address - Fax:601-833-3183
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS225686122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060249Medicaid