Provider Demographics
NPI:1013306158
Name:JOHNNY L BAKKER DDS PA
Entity Type:Organization
Organization Name:JOHNNY L BAKKER DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAKKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:479-751-8820
Mailing Address - Street 1:418 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5334
Mailing Address - Country:US
Mailing Address - Phone:479-751-8820
Mailing Address - Fax:479-751-3117
Practice Address - Street 1:418 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5334
Practice Address - Country:US
Practice Address - Phone:479-751-8820
Practice Address - Fax:479-751-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2398261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental