Provider Demographics
NPI:1750314761
Name:KIMBERLEY A BAKER, DDS, PA
Entity Type:Organization
Organization Name:KIMBERLEY A BAKER, DDS, PA
Other - Org Name:ROANOKE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-430-1212
Mailing Address - Street 1:1405 CANNON PKWY
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-3620
Mailing Address - Country:US
Mailing Address - Phone:817-430-1212
Mailing Address - Fax:817-491-0154
Practice Address - Street 1:1405 CANNON PKWY
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-3620
Practice Address - Country:US
Practice Address - Phone:817-430-1212
Practice Address - Fax:817-491-0154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty