Provider Demographics
NPI:1992868996
Name:BAKER, SUSAN JEAN (DDS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:BAKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 MAIN ST STE 3
Mailing Address - Street 2:3
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3041
Mailing Address - Country:US
Mailing Address - Phone:307-332-3434
Mailing Address - Fax:307-332-5955
Practice Address - Street 1:933 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3041
Practice Address - Country:US
Practice Address - Phone:307-332-3434
Practice Address - Fax:307-332-5955
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX178361223G0001X
WY1427122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice