Provider Demographics
NPI:1982762894
Name:BAKUS, ERIC ROBERT
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ROBERT
Last Name:BAKUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HERRICK PARK DR
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1422
Mailing Address - Country:US
Mailing Address - Phone:517-423-4050
Mailing Address - Fax:
Practice Address - Street 1:120 HERRICK PARK DR
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-1422
Practice Address - Country:US
Practice Address - Phone:517-423-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0151201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice