Provider Demographics
NPI:1205089851
Name:BAUMAN, MICHAEL THOMAS (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:BAUMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 SOUTHWEST BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2430
Mailing Address - Country:US
Mailing Address - Phone:573-635-7216
Mailing Address - Fax:573-635-2646
Practice Address - Street 1:1400 SOUTHWEST BLVD STE C
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2430
Practice Address - Country:US
Practice Address - Phone:573-635-7216
Practice Address - Fax:573-635-2646
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0087511223S0112X
UT827082499241223S0112X
MO20140416821223S0112X
WADR 600354031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery