Provider Demographics
NPI:1154370450
Name:BAKER, ROXANN (DDS)
Entity type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20905 GREENFIELD RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5360
Mailing Address - Country:US
Mailing Address - Phone:248-569-3490
Mailing Address - Fax:248-569-3471
Practice Address - Street 1:20905 GREENFIELD RD
Practice Address - Street 2:SUITE 208
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5360
Practice Address - Country:US
Practice Address - Phone:248-569-3490
Practice Address - Fax:248-569-3471
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI130771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1759109Medicaid