Provider Demographics
NPI:1730106683
Name:BALTHAZAR, NICOLE VERONICA (DMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:VERONICA
Last Name:BALTHAZAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 RTE 130
Mailing Address - Street 2:BLDG A9
Mailing Address - City:FORESTDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02644
Mailing Address - Country:US
Mailing Address - Phone:508-888-3088
Mailing Address - Fax:508-888-3626
Practice Address - Street 1:280 RTE 130
Practice Address - Street 2:BLDG A9
Practice Address - City:FORESTDALE
Practice Address - State:MA
Practice Address - Zip Code:02644
Practice Address - Country:US
Practice Address - Phone:508-888-3088
Practice Address - Fax:508-888-3626
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA197151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice