Provider Demographics
NPI:1578626966
Name:DONALD G. TRAXLER, D.M.D., P.A.
Entity Type:Organization
Organization Name:DONALD G. TRAXLER, D.M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:TRAXLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-776-6630
Mailing Address - Street 1:303A S ARCHUSA AVE
Mailing Address - Street 2:P. O. BOX 159
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-2325
Mailing Address - Country:US
Mailing Address - Phone:601-776-6630
Mailing Address - Fax:601-776-3825
Practice Address - Street 1:303A S ARCHUSA AVE
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-2325
Practice Address - Country:US
Practice Address - Phone:601-776-6630
Practice Address - Fax:601-776-3825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS185679261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660382Medicaid