Provider Demographics
NPI:1205917499
Name:BAUER, JOACHIM O (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JOACHIM
Middle Name:O
Last Name:BAUER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23 GLEN ED PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3333
Mailing Address - Country:US
Mailing Address - Phone:618-692-1044
Mailing Address - Fax:618-692-9809
Practice Address - Street 1:23 GLEN ED PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-692-1044
Practice Address - Fax:618-692-9809
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190139491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics