Provider Demographics
NPI:1265729859
Name:BAXTER, TRACE RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACE
Middle Name:RYAN
Last Name:BAXTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LONO AVE SUITE 370
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732
Mailing Address - Country:US
Mailing Address - Phone:808-871-6337
Mailing Address - Fax:808-871-8073
Practice Address - Street 1:33 LONO AVE SUITE 370
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732
Practice Address - Country:US
Practice Address - Phone:808-871-6337
Practice Address - Fax:808-871-8073
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT2492122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice