Healthcare Provider Details

I. General information

NPI: 1629199054
Provider Name (Legal Business Name): LAWRENCE BRADLEY BAKER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SOUTHTOWN BLVD
OWENSBORO KY
42301-7481
US

IV. Provider business mailing address

1300 SOUTHTOWN BLVD
OWENSBORO KY
42301-7481
US

V. Phone/Fax

Practice location:
  • Phone: 270-684-7433
  • Fax: 270-685-4114
Mailing address:
  • Phone: 270-684-7433
  • Fax: 270-685-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberKY6187
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: