Healthcare Provider Details

I. General information

NPI: 1649746066
Provider Name (Legal Business Name): ROMMEL K BAL DDS A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 SAINT MARKS PLZ STE 1
STOCKTON CA
95207-6411
US

IV. Provider business mailing address

1545 SAINT MARKS PLZ STE 1
STOCKTON CA
95207-6411
US

V. Phone/Fax

Practice location:
  • Phone: 209-957-1244
  • Fax: 209-957-2591
Mailing address:
  • Phone: 209-957-1244
  • Fax: 209-957-2591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROMMEL KAUR BAL
Title or Position: PRESIDENT
Credential: DDS
Phone: 209-957-1244