Provider Demographics
NPI:1457361941
Name:BAXA DENTAL INC., S.C.
Entity Type:Organization
Organization Name:BAXA DENTAL INC., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAXA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-985-3316
Mailing Address - Street 1:35791 OSSEO RD
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:INDEPENDENCE
Mailing Address - State:WI
Mailing Address - Zip Code:54747-9096
Mailing Address - Country:US
Mailing Address - Phone:715-985-3316
Mailing Address - Fax:715-985-2542
Practice Address - Street 1:35791 OSSEO RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:WI
Practice Address - Zip Code:54747-9096
Practice Address - Country:US
Practice Address - Phone:715-985-3316
Practice Address - Fax:715-985-2542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00030451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI76993OtherWPS
WI33445800Medicaid