MEDICARE: BRENT L BAKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	137881-9922	UT

General Provider Information

NPI Number	:	1033312806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT L BAKER

Provider Business Mailing Address
First Line	:	2854 W 4700 S
Second Line	:	SUITE C
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84118-2102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2854 W 4700 S
Second Line	:	SUITE C
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84118-2102
Country	:	US
Telephone Number	:	801-964-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	07/08/2007

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