Provider Demographics
NPI:1912136953
Name:BAPTIST, BRIAN D (DDS, MS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:BAPTIST
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 W 111TH ST STE 111
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-4037
Mailing Address - Country:US
Mailing Address - Phone:773-233-1249
Mailing Address - Fax:
Practice Address - Street 1:3838 W 111TH ST STE 111
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-4037
Practice Address - Country:US
Practice Address - Phone:773-233-1249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist