Provider Demographics
NPI:1811355456
Name:BAE, GEON (DMD)
Entity type:Individual
Prefix:
First Name:GEON
Middle Name:
Last Name:BAE
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 1:3470 E MERIDIAN PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7294
Mailing Address - Country:US
Mailing Address - Phone:907-373-8684
Mailing Address - Fax:907-373-8465
Practice Address - Street 1:3340 PROVIDENCE DR STE 552
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-336-1234
Practice Address - Fax:907-336-4321
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1395291223G0001X, 1223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program