Provider Demographics
NPI:1215585302
Name:BALDERAS, GEOVANNY (DMD)
Entity type:Individual
Prefix:
First Name:GEOVANNY
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7517 CLEMSON CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-7230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19340 PROMENADE DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-6500
Practice Address - Country:US
Practice Address - Phone:571-333-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-31
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014169491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice