MEDICARE: BAKER FAMILY DENTISTRY, P.C.

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	122300000X	Dentist	12009106	IN

General Provider Information

NPI Number	:	1972873925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAKER FAMILY DENTISTRY, P.C.

Provider Business Mailing Address
First Line	:	4217 E 3RD ST
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-5550
Country	:	US
Telephone Number	:	812-332-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4217 E 3RD ST
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-5550
Country	:	US
Telephone Number	:	812-332-2000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LISA J BAKER
Credential	:	DDS
Telephone Number	:	812-332-2000

Provider Enumeration Date	:	01/09/2012
Last Update Date	:	01/09/2012

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