Provider Demographics
NPI:1578720967
Name:BAKER, DEST, BAKER, DDS, PLLC
Entity Type:Organization
Organization Name:BAKER, DEST, BAKER, DDS, PLLC
Other - Org Name:KINGS MOUNTAIN MEDICAID DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED AGENT/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:DEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-547-1279
Mailing Address - Street 1:8305 UNIVERSITY EXEC PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1361
Mailing Address - Country:US
Mailing Address - Phone:704-547-1279
Mailing Address - Fax:704-547-8383
Practice Address - Street 1:107 E MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3442
Practice Address - Country:US
Practice Address - Phone:704-739-4473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC52831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890175TMedicaid