Provider Demographics
NPI:1639541659
Name:BALBOA AND ASSOCIATES DENTAL GROUP
Entity Type:Organization
Organization Name:BALBOA AND ASSOCIATES DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BALBOA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-503-5122
Mailing Address - Street 1:14527 SW 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7801
Mailing Address - Country:US
Mailing Address - Phone:305-503-5122
Mailing Address - Fax:305-328-9636
Practice Address - Street 1:14527 SW 42ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-7801
Practice Address - Country:US
Practice Address - Phone:305-503-5122
Practice Address - Fax:305-328-9636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN204341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty