Healthcare Provider Details

I. General information

NPI: 1154631364
Provider Name (Legal Business Name): GREG R. BAKER DENTAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DRIVE
HAZARD KY
41701-9421
US

IV. Provider business mailing address

145 CITIZENS LANE SUITE B
HAZARD KY
41701-1320
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-1331
  • Fax:
Mailing address:
  • Phone: 606-435-7676
  • Fax: 606-436-5175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6322
License Number StateKY

VIII. Authorized Official

Name: MR. GREG R BAKER
Title or Position: DENTIST
Credential: DMD
Phone: 606-435-7676