Healthcare Provider Details

I. General information

NPI: 1922120377
Provider Name (Legal Business Name): PABLO GONZALEZ BALZAR DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5723 NE BOTHELL WAY STE C
KENMORE WA
98028-9404
US

IV. Provider business mailing address

9225 122ND CT NE #K506
KIRKLAND WA
98033-5889
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-9111
  • Fax: 425-489-1923
Mailing address:
  • Phone: 617-642-3932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE10694
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: