Healthcare Provider Details

I. General information

NPI: 1023098993
Provider Name (Legal Business Name): WILLIAM R BAKER IV D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 S 6TH ST
BRAINERD MN
56401-4599
US

IV. Provider business mailing address

1903 S 6TH ST
BRAINERD MN
56401-4599
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-1728
  • Fax: 218-829-1729
Mailing address:
  • Phone: 218-829-1728
  • Fax: 218-829-1729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD10467
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: