Healthcare Provider Details

I. General information

NPI: 1346483625
Provider Name (Legal Business Name): DARLENE BALLESTEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 04/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4149 TWEEDY BLVD STE J
SOUTH GATE CA
90280-6167
US

IV. Provider business mailing address

13702 FLALLON AVE
NORWALK CA
90650-3947
US

V. Phone/Fax

Practice location:
  • Phone: 323-567-3333
  • Fax:
Mailing address:
  • Phone: 562-651-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: