Provider Demographics
NPI:1427166057
Name:BALDEN GALLO MICHELS PROF DENTAL CORP
Entity type:Organization
Organization Name:BALDEN GALLO MICHELS PROF DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-261-1670
Mailing Address - Street 1:290 LANDIS AVE
Mailing Address - Street 2:SUITE A & B
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2636
Mailing Address - Country:US
Mailing Address - Phone:619-691-0121
Mailing Address - Fax:619-691-0841
Practice Address - Street 1:290 LANDIS AVE
Practice Address - Street 2:SUITE A & B
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2636
Practice Address - Country:US
Practice Address - Phone:619-691-0121
Practice Address - Fax:619-691-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty