Provider Demographics
NPI:1750301602
Name:BAKER, MELVIN O (DMD)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:O
Last Name:BAKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 TATE STREET
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014
Mailing Address - Country:US
Mailing Address - Phone:770-787-2230
Mailing Address - Fax:770-787-0508
Practice Address - Street 1:4115 TATE ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2554
Practice Address - Country:US
Practice Address - Phone:770-787-2230
Practice Address - Fax:770-787-0508
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100365OtherAVESIS
WI9180656OtherDORAL