Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 22775 | NE |
NPI | 1508967639 |
---|---|
Provider Name | Larry L Baker |
First Address | Hastings, NE 68902-0947 |
Second Address | Hastings, NE 68901-3908 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10025150000 | (05) | NE |
I06777 | (02) |