Provider Demographics
NPI:1013049634
Name:BAUMANN, ANDREA LOU (DDS MS)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LOU
Last Name:BAUMANN
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 TENNESSEE ST APT 301
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-4484
Mailing Address - Country:US
Mailing Address - Phone:951-533-3563
Mailing Address - Fax:
Practice Address - Street 1:126 W BOND AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3909
Practice Address - Country:US
Practice Address - Phone:870-735-7805
Practice Address - Fax:870-735-7853
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADT0348161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4142OtherARKANSAS STATE DENTAL LICENSE
CADT034816OtherDENTAL LICENSE