Provider Demographics
NPI:1306290523
Name:IGNACIO ALBERTO BAEZ DMD PA
Entity type:Organization
Organization Name:IGNACIO ALBERTO BAEZ DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:BAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-310-6627
Mailing Address - Street 1:300 GATLIN AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6951
Mailing Address - Country:US
Mailing Address - Phone:407-310-6627
Mailing Address - Fax:
Practice Address - Street 1:300 GATLIN AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6951
Practice Address - Country:US
Practice Address - Phone:407-310-6627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0007199261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002854600Medicaid
FL075096496OtherMED WAIVER