=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023793650
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNA BAUER DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2023
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 BURTON ST
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29301-5400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-576-7169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4551 KENT RD
-----------------------------------------------------
City | ANDREWS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29510-6756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-833-2606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10556
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------