Healthcare Provider Details

I. General information

NPI: 1750314761
Provider Name (Legal Business Name): KIMBERLEY A BAKER, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CANNON PKWY
ROANOKE TX
76262-3620
US

IV. Provider business mailing address

1405 CANNON PKWY
ROANOKE TX
76262-3620
US

V. Phone/Fax

Practice location:
  • Phone: 817-430-1212
  • Fax: 817-491-0154
Mailing address:
  • Phone: 817-430-1212
  • Fax: 817-491-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19129
License Number StateTX

VIII. Authorized Official

Name: DR. KIMBERLEY ANNE BAKER
Title or Position: PRESIDENT
Credential: DDS
Phone: 817-430-1212