Provider Demographics
NPI:1396546339
Name:BAKER, NICHOLAS CHARLES
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CHARLES
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 N SAWYER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-4280
Mailing Address - Country:US
Mailing Address - Phone:920-233-1030
Mailing Address - Fax:
Practice Address - Street 1:230 N SAWYER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902
Practice Address - Country:US
Practice Address - Phone:920-233-1030
Practice Address - Fax:920-233-7398
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI6001808-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program