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General NPI Number Information
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NPI Number | 1215585302
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Entity Type | Individual
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Provider Name | GEOVANNY BALDERAS DMD
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Gender | Male
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Dates
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Enumeration Date | 08/31/2019
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Last Update Date | 07/08/2020
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Provider Practice Location Address
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Address Line | 19340 PROMENADE DR
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City | LEESBURG
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State | VA
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Zip | 20176-6500
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Country | US
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Telephone | 571-333-8558
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Fax |
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Provider Business Mailing Address
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Address Line | 7517 CLEMSON CT
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City | MANASSAS
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State | VA
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Zip | 20109-7230
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401416949
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License Number State | VA
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