Provider Demographics
NPI:1720535289
Name:BAXTER, JAMIE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:
Last Name:BAXTER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1484 ANKLAM RD
Mailing Address - Street 2:
Mailing Address - City:WEYAUWEGA
Mailing Address - State:WI
Mailing Address - Zip Code:54983
Mailing Address - Country:US
Mailing Address - Phone:920-312-4152
Mailing Address - Fax:
Practice Address - Street 1:4182 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8652
Practice Address - Country:US
Practice Address - Phone:920-734-4649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002710-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist