MEDICARE: DR. GENE MARK BAINES D.M.D.

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	MS1905-80	MS

General Provider Information

NPI Number	:	1396748067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GENE MARK BAINES D.M.D.

Provider Business Mailing Address
First Line	:	509 HIGHWAY 82 W
Second Line	:
City	:	GREENWOOD
State	:	MS
Zip	:	38930-5053
Country	:	US
Telephone Number	:	662-455-3192
Fax Number	:	662-455-3170

Provider Business Practice Location Address
First Line	:	509 HIGHWAY 82 W
Second Line	:
City	:	GREENWOOD
State	:	MS
Zip	:	38930-5053
Country	:	US
Telephone Number	:	662-455-3192
Fax Number	:	662-455-3170

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	08/30/2012

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