Basic Information
Provider Information
NPI: 1003141722
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BAUER
FirstName: MATTHEW
MiddleName: J
NamePrefix: DR.
NameSuffix:  
Credential: DMD MS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 150 WEISS RD
Address2: SUITE 102
City: COTTLEVILLE
State: MO
PostalCode: 633760045
CountryCode: US
TelephoneNumber: 6364472083
FaxNumber: 6364472059
Practice Location
Address1: 150 WEISS RD
Address2: SUITE 102
City: COTTLEVILLE
State: MO
PostalCode: 633760045
CountryCode: US
TelephoneNumber: 6364472083
FaxNumber: 6364472059
Other Information
ProviderEnumerationDate: 10/14/2009
LastUpdateDate: 05/23/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223X0400X2011004362MOY Dental ProvidersDentistOrthodontics and Dentofacial Orthopedics
1223X0400X019026933ILN Dental ProvidersDentistOrthodontics and Dentofacial Orthopedics

No ID Information.


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