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General NPI Number Information
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NPI Number | 1427166057
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Entity Type | Organization
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Legal Business Name | BALDEN GALLO MICHELS PROF DENTAL CORP
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 290 LANDIS AVE SUITE A & B
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City | CHULA VISTA
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State | CA
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Zip | 91910-2636
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Country | US
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Telephone | 619-691-0121
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Fax | 619-691-0841
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Provider Business Mailing Address
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Address Line | 290 LANDIS AVE SUITE A & B
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City | CHULA VISTA
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State | CA
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Zip | 91910-2636
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Country | US
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Telephone | 619-691-0121
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Fax | 619-691-0841
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Authorized Official
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Title or Position | REGIONAL MANAGER
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Name | NICOLE REID
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Credential |
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Telephone | 619-261-1670
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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 | 31040
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License Number State | CA
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