Provider Demographics
NPI:1578686689
Name:BAUER, JEFFREY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
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 1:206 MEADOW MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8162
Mailing Address - Country:US
Mailing Address - Phone:254-666-6292
Mailing Address - Fax:254-666-2190
Practice Address - Street 1:206 MEADOW MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8162
Practice Address - Country:US
Practice Address - Phone:254-666-6292
Practice Address - Fax:254-666-2190
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX150121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158753701Medicaid