Provider Demographics
NPI:1699832410
Name:BAKER, BRUCE ARTHUR (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ARTHUR
Last Name:BAKER
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 1:415 N 2ND ST
Mailing Address - Street 2:SUITE 2 D
Mailing Address - City:TOWER
Mailing Address - State:MN
Mailing Address - Zip Code:55790-0417
Mailing Address - Country:US
Mailing Address - Phone:218-753-2405
Mailing Address - Fax:218-361-3277
Practice Address - Street 1:415 N 2ND ST
Practice Address - Street 2:SUITE 2 D
Practice Address - City:TOWER
Practice Address - State:MN
Practice Address - Zip Code:55790-0417
Practice Address - Country:US
Practice Address - Phone:218-753-2405
Practice Address - Fax:218-361-3277
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN97351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN958520600Medicaid