Healthcare Provider Details

I. General information

NPI: 1154355162
Provider Name (Legal Business Name): PHILIP ROBERT BAYNE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E MAYNE ST
BLUE GRASS IA
52726-9718
US

IV. Provider business mailing address

133 E MAYNE ST PO BOX 98
BLUE GRASS IA
52726-9718
US

V. Phone/Fax

Practice location:
  • Phone: 563-381-4830
  • Fax: 563-381-5071
Mailing address:
  • Phone: 563-381-4830
  • Fax: 563-381-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7609
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: