Basic Information
| Provider Information | |||||||||
| NPI: | 1003141722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD MS | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 2011004362 | MO | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223X0400X | 019026933 | IL | N | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.