Healthcare Provider Details

I. General information

NPI: 1215585302
Provider Name (Legal Business Name): GEOVANNY BALDERAS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2019
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 OAKWOOD DR
BRIDGEWATER VA
22812-9544
US

IV. Provider business mailing address

7517 CLEMSON CT
MANASSAS VA
20109-7230
US

V. Phone/Fax

Practice location:
  • Phone: 540-828-2312
  • Fax: 540-828-2312
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401416949
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: