Provider Demographics
NPI:1427256908
Name:BAKKE, DALE WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:WAYNE
Last Name:BAKKE
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:PO BOX 380
Mailing Address - Street 2:
Mailing Address - City:TRIPP
Mailing Address - State:SD
Mailing Address - Zip Code:57376-0380
Mailing Address - Country:US
Mailing Address - Phone:605-935-6089
Mailing Address - Fax:
Practice Address - Street 1:310 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TRIPP
Practice Address - State:SD
Practice Address - Zip Code:57376-0380
Practice Address - Country:US
Practice Address - Phone:605-935-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM5411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7803900Medicaid