Healthcare Provider Details

I. General information

NPI: 1215378039
Provider Name (Legal Business Name): GHEZAL BALKHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38062 MARTHA AVE
FREMONT CA
94536-3809
US

IV. Provider business mailing address

1301 STEVENSON BLVD # 324
FREMONT CA
94538-2984
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-9292
  • Fax: 510-792-9296
Mailing address:
  • Phone: 510-688-9707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number80318
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: