Healthcare Provider Details

I. General information

NPI: 1992902423
Provider Name (Legal Business Name): DAVID RUSSELL BAER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 PEPPER LANE STE A
PUEBLO CO
81005
US

IV. Provider business mailing address

2041 PEPPER LANE STE A
PUEBLO CO
81005
US

V. Phone/Fax

Practice location:
  • Phone: 719-696-9009
  • Fax: 719-924-9493
Mailing address:
  • Phone: 719-696-9009
  • Fax: 719-924-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9645
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2643
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN00009645
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: