Healthcare Provider Details

I. General information

NPI: 1295148880
Provider Name (Legal Business Name): ANDREW MARK BAKER DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 CASCADE RD SE STE 208
GRAND RAPIDS MI
49546-3665
US

IV. Provider business mailing address

4500 CASCADE RD SE STE 208
GRAND RAPIDS MI
49546-3665
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-5000
  • Fax: 616-977-0020
Mailing address:
  • Phone: 616-977-5000
  • Fax: 616-977-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2901601271
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: