Healthcare Provider Details

I. General information

NPI: 1134116965
Provider Name (Legal Business Name): DOUGLAS J BAKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 L ST
ORD NE
68862-1425
US

IV. Provider business mailing address

PO BOX 224
ORD NE
68862-0224
US

V. Phone/Fax

Practice location:
  • Phone: 308-728-3756
  • Fax: 308-728-3207
Mailing address:
  • Phone: 308-728-3756
  • Fax: 308-728-3207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6300
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: