Provider Demographics
NPI:1194739276
Name:BAUER, CHARLES DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DALE
Last Name:BAUER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 N KANSAS AVE
Mailing Address - Street 2:SUITE #202
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-2615
Mailing Address - Country:US
Mailing Address - Phone:402-462-6410
Mailing Address - Fax:402-462-4463
Practice Address - Street 1:2115 N KANSAS AVE
Practice Address - Street 2:SUITE #202
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-2615
Practice Address - Country:US
Practice Address - Phone:402-462-6410
Practice Address - Fax:402-462-4463
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE45651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47067078700Medicaid
NE05473OtherBLUE CROSS BLUE SHIELD
NE05473OtherBLUE CROSS BLUE SHIELD