MEDICARE: LIONEL EVERETT BAIR II D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4012	OK

General Provider Information

NPI Number	:	1386636967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIONEL EVERETT BAIR II D.D.S.

Provider Business Mailing Address
First Line	:	400 FAIRVIEW AVE
Second Line	:	SUITE # 6
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1920
Country	:	US
Telephone Number	:	580-765-2589
Fax Number	:	580-762-2199

Provider Business Practice Location Address
First Line	:	400 FAIRVIEW AVE
Second Line	:	SUITE # 6
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1920
Country	:	US
Telephone Number	:	580-765-2589
Fax Number	:	580-762-2199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/08/2007

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