Provider Demographics
NPI:1376243758
Name:BALLESTEROS, KARINA (RDHAP)
Entity Type:Individual
Prefix:
First Name:KARINA
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E VINEYARD AVE
Mailing Address - Street 2:STE 119 #112
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1498 N VASCO RD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-9213
Practice Address - Country:US
Practice Address - Phone:925-454-1132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA944125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA944OtherDENTAL HYGIENE BOARD OF CALIFORNIA