Provider Demographics
NPI:1841219524
Name:BAKER, BRYAN SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:SCOTT
Last Name:BAKER
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:PO BOX 827
Mailing Address - Street 2:107 E MOUNTAIN STREET
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-0827
Mailing Address - Country:US
Mailing Address - Phone:704-484-2347
Mailing Address - Fax:
Practice Address - Street 1:107 E MOUNTAIN ST
Practice Address - Street 2:107 E MOUNTAIN STREET
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3442
Practice Address - Country:US
Practice Address - Phone:704-484-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC5693122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990331Medicaid