=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871663674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOFIA J BALTAZAR DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24264 SAN FERNANDO RD
-----------------------------------------------------
City | NEWHALL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91321-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-290-2825
-----------------------------------------------------
Fax | 661-290-2864
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24264 SAN FERNANDO RD
-----------------------------------------------------
City | NEWHALL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91321-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-290-2825
-----------------------------------------------------
Fax | 661-290-2864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SOFIA J BALTAZAR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 661-290-2825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 49466
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------