Provider Demographics
NPI:1053051086
Name:BAK, LEEANN (DMD)
Entity type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:BAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08730-1413
Mailing Address - Country:US
Mailing Address - Phone:732-528-6336
Mailing Address - Fax:
Practice Address - Street 1:421 HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:BRIELLE
Practice Address - State:NJ
Practice Address - Zip Code:08730-1413
Practice Address - Country:US
Practice Address - Phone:732-528-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI029113001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice