Provider Demographics
NPI:1356466726
Name:BAXTER, DOUG PORTER (DMD)
Entity type:Individual
Prefix:DR
First Name:DOUG
Middle Name:PORTER
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 1:152 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-8200
Mailing Address - Country:US
Mailing Address - Phone:770-867-4175
Mailing Address - Fax:770-868-1564
Practice Address - Street 1:152 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8200
Practice Address - Country:US
Practice Address - Phone:770-867-4175
Practice Address - Fax:770-868-1564
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice