Provider Demographics
NPI:1205933926
Name:BAUMGARTNER, KENNETH ROGER (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROGER
Last Name:BAUMGARTNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:BAUMGARTNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:18175 N HIGHWAY ONE
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437
Mailing Address - Country:US
Mailing Address - Phone:707-964-0440
Mailing Address - Fax:707-964-8373
Practice Address - Street 1:18175 N HIGHWAY ONE
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-964-0440
Practice Address - Fax:707-964-8373
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB34056Medicaid
DS034056OtherBCBS
825575OtherUNITED CONCORDIA