Provider Demographics
NPI:1962523001
Name:BAKER COLLEGE OF PORT HURON
Entity type:Organization
Organization Name:BAKER COLLEGE OF PORT HURON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-985-3729
Mailing Address - Street 1:3403 LAPEER ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2597
Mailing Address - Country:US
Mailing Address - Phone:810-985-3729
Mailing Address - Fax:810-985-7066
Practice Address - Street 1:3403 LAPEER ROAD
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2597
Practice Address - Country:US
Practice Address - Phone:810-985-3729
Practice Address - Fax:810-985-7066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI015451261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental