MEDICARE: CARREL D BALDERSTON JR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	42119	CA
2	1223G0001X	General Practice Dentistry	42119	CA

General Provider Information

NPI Number	:	1750580288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARREL D BALDERSTON JR. DDS

Provider Business Mailing Address
First Line	:	1074 EAST AVE STE U
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95926-1052
Country	:	US
Telephone Number	:	530-342-8580
Fax Number	:	530-873-2104

Provider Business Practice Location Address
First Line	:	1074 EAST AVE STE U
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95926-1052
Country	:	US
Telephone Number	:	530-342-8580
Fax Number	:	530-873-2104

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2007
Last Update Date	:	02/09/2022

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