Basic Information
| Provider Information | |||||||||
| NPI: | 1174653570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349363329 | ||||||||
| FaxNumber: | 7346154784 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349363329 | ||||||||
| FaxNumber: | 7346154784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901015158 | MI | X | Dental Providers | Dentist | 1223E0200X | 2901015158 | MI | X | Dental Providers | Dentist | Endodontics |
ID Information
| ID | Type | State | Issuer | Description | D158980 | 01 | MI | BCBSOF MICHIGAN | OTHER |