Provider Demographics
NPI:1770695892
Name:BAXA, WILLIAM J
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:BAXA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00030451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI76-993OtherWPS
WI33445800Medicaid
WI391597408010OtherBCBS