Provider Demographics
NPI:1912432246
Name:BAKER, CHEZDAN
Entity Type:Individual
Prefix:
First Name:CHEZDAN
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:US ARMY DENTAL HEALTH ACTIVITY BLDG-6837 NORMANDY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7302
Mailing Address - Country:US
Mailing Address - Phone:910-396-2607
Mailing Address - Fax:
Practice Address - Street 1:US ARMY DENTAL COMMAND FORT BLISS
Practice Address - Street 2:2954 CARRINGTON RD
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79916
Practice Address - Country:US
Practice Address - Phone:915-742-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX387591223E0200X
390200000X
VA04014156711223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program