Healthcare Provider Details

I. General information

NPI: 1548870942
Provider Name (Legal Business Name): AUSTIN BAULDRY DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 DOUGLAS BLVD STE A
GRANITE BAY CA
95746-6299
US

IV. Provider business mailing address

9401 RAWHIDE LN
ROSEVILLE CA
95747-9715
US

V. Phone/Fax

Practice location:
  • Phone: 916-677-1216
  • Fax:
Mailing address:
  • Phone: 209-405-1247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number105140
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: