Provider Demographics
NPI:1154416477
Name:BALDERRAMA, DANIEL VASQUES (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:VASQUES
Last Name:BALDERRAMA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-7666
Mailing Address - Country:US
Mailing Address - Phone:903-938-5662
Mailing Address - Fax:903-938-7392
Practice Address - Street 1:2602 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75672-7666
Practice Address - Country:US
Practice Address - Phone:903-938-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice