Provider Demographics
NPI:1457453151
Name:BALTHAZOR, TERRY DORSEY (DDS)
Entity Type:Individual
Prefix:MRS
First Name:TERRY
Middle Name:DORSEY
Last Name:BALTHAZOR
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 1:491 FOREST EDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-2499
Mailing Address - Country:US
Mailing Address - Phone:719-687-6366
Mailing Address - Fax:719-687-6388
Practice Address - Street 1:491 FOREST EDGE ROAD
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-2499
Practice Address - Country:US
Practice Address - Phone:719-687-6366
Practice Address - Fax:719-687-6388
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice