Healthcare Provider Details

I. General information

NPI: 1053496083
Provider Name (Legal Business Name): DWIGHT DOUGLAS BAKER D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 JOHN ADAMS PKWY
IDAHO FALLS ID
83401-4366
US

IV. Provider business mailing address

1900 JOHN ADAMS PKWY
IDAHO FALLS ID
83401-4366
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-0644
  • Fax: 208-524-6100
Mailing address:
  • Phone: 208-524-0644
  • Fax: 208-524-6100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-1911-OR
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: