Provider Demographics
NPI:1467749283
Name:BAXTER, KSENIA G (DMD)
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:G
Last Name:BAXTER
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 1:2 STONY HILL RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-1063
Mailing Address - Country:US
Mailing Address - Phone:203-792-2263
Mailing Address - Fax:
Practice Address - Street 1:2 STONY HILL RD
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801
Practice Address - Country:US
Practice Address - Phone:203-792-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT108121223G0001X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004011136Medicaid