Provider Demographics
NPI:1609093988
Name:BAINES, COLLEEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:
Last Name:BAINES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 FARABEE DR N
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5915
Mailing Address - Country:US
Mailing Address - Phone:765-447-7052
Mailing Address - Fax:765-449-1333
Practice Address - Street 1:103 FARABEE DR N
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5915
Practice Address - Country:US
Practice Address - Phone:765-447-7052
Practice Address - Fax:765-449-1333
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010256A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist