Provider Demographics
NPI:1417309568
Name:BALDINO-GOMEZ, MARY ANN (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:BALDINO-GOMEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 GRASS LAKE RD.
Mailing Address - Street 2:STE. C.
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5607
Mailing Address - Country:US
Mailing Address - Phone:847-265-9022
Mailing Address - Fax:847-265-9023
Practice Address - Street 1:2450 GRASS LAKE RD.
Practice Address - Street 2:STE. C.
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5607
Practice Address - Country:US
Practice Address - Phone:847-265-9022
Practice Address - Fax:847-265-9023
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020836122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist