Healthcare Provider Details

I. General information

NPI: 1508070178
Provider Name (Legal Business Name): LEO PAUL BALDERAMOS DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 SAINT MICHAELS DRIVE SUITE D
SANTA FE NM
87505
US

IV. Provider business mailing address

409 SAINT MICHAELS DRIVE SUITE D
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-7373
  • Fax: 505-989-1552
Mailing address:
  • Phone: 505-983-7373
  • Fax: 505-989-1552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1828
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number16475
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: