Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | D-1911-OR | ID |
NPI | 1053496083 |
---|---|
Provider Name | Dr. Dwight Douglas Baker |
First Address | Idaho Falls, ID 83401-4366 |
Second Address | Idaho Falls, ID 83401-4366 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2006 |
Last Update Date | 08/07/2007 |