Provider Demographics
NPI:1790798031
Name:BALTAZAR, WILFRED JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILFRED
Middle Name:
Last Name:BALTAZAR
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9329 MIRA MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4816
Mailing Address - Country:US
Mailing Address - Phone:858-693-8448
Mailing Address - Fax:
Practice Address - Street 1:9329 MIRA MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4816
Practice Address - Country:US
Practice Address - Phone:858-693-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice