Provider Demographics
NPI:1912051772
Name:BACA, PHILLP M
Entity type:Individual
Prefix:DR
First Name:PHILLP
Middle Name:M
Last Name:BACA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:PHILLIP
Other - Middle Name:M
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:16127 KASOTA RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2204
Mailing Address - Country:US
Mailing Address - Phone:760-946-1700
Mailing Address - Fax:760-946-2414
Practice Address - Street 1:16127 KASOTA RD
Practice Address - Street 2:SUITE 106
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2204
Practice Address - Country:US
Practice Address - Phone:760-946-1700
Practice Address - Fax:760-946-2414
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD326911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice