Provider Demographics
NPI:1225924194
Name:BALTZELL, JORGE ANTONIO (DDS)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ANTONIO
Last Name:BALTZELL
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 1:7424 BOJRAB DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-4153
Mailing Address - Country:US
Mailing Address - Phone:317-273-9190
Mailing Address - Fax:
Practice Address - Street 1:6412 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46819-1550
Practice Address - Country:US
Practice Address - Phone:260-747-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014795A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist