Provider Demographics
NPI:1902017049
Name:BACKER, GARY WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
Last Name:BACKER
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 1:4004 BALMORAL DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6402
Mailing Address - Country:US
Mailing Address - Phone:256-883-0030
Mailing Address - Fax:256-883-0235
Practice Address - Street 1:4004 BALMORAL DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6402
Practice Address - Country:US
Practice Address - Phone:256-883-0030
Practice Address - Fax:256-883-0235
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice