Healthcare Provider Details

I. General information

NPI: 1730106683
Provider Name (Legal Business Name): NICOLE VERONICA BALTHAZAR DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 RTE 130 BLDG A9
FORESTDALE MA
02644
US

IV. Provider business mailing address

280 RTE 130 BLDG A9
FORESTDALE MA
02644
US

V. Phone/Fax

Practice location:
  • Phone: 508-888-3088
  • Fax: 508-888-3626
Mailing address:
  • Phone: 508-888-3088
  • Fax: 508-888-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMA19715
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: