MEDICARE: DR. KATHLEEN MARIE BALES DDS, MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	51548	CA

General Provider Information

NPI Number	:	1760621593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN MARIE BALES DDS, MS

Provider Business Mailing Address
First Line	:	1713 NOVATO BLVD
Second Line	:
City	:	NOVATO
State	:	CA
Zip	:	94947-3014
Country	:	US
Telephone Number	:	415-897-3141
Fax Number	:	415-898-3445

Provider Business Practice Location Address
First Line	:	1713 NOVATO BLVD
Second Line	:
City	:	NOVATO
State	:	CA
Zip	:	94947-3014
Country	:	US
Telephone Number	:	415-897-3141
Fax Number	:	415-898-3445

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

Provider Enumeration Date	:	02/18/2009
Last Update Date	:	02/18/2009

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