Provider Demographics
NPI:1649348285
Name:BAHOS, GUS (DMD)
Entity type:Individual
Prefix:DR
First Name:GUS
Middle Name:
Last Name:BAHOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401-0726
Mailing Address - Country:US
Mailing Address - Phone:251-578-1163
Mailing Address - Fax:251-578-9875
Practice Address - Street 1:1115 AZALEA PL
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1318
Practice Address - Country:US
Practice Address - Phone:251-809-3925
Practice Address - Fax:251-809-6058
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3823122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-19195OtherBLUE CROSS BLUE SHIELD
AL130949Medicaid