Provider Demographics
NPI:1811227887
Name:BASALLAJE, TEODORICO (CFA)
Entity Type:Individual
Prefix:
First Name:TEODORICO
Middle Name:
Last Name:BASALLAJE
Suffix:
Gender:M
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 LA SIERRA DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4139
Mailing Address - Country:US
Mailing Address - Phone:214-382-1909
Mailing Address - Fax:214-382-1903
Practice Address - Street 1:5445 LA SIERRA DR
Practice Address - Street 2:SUITE 410
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4139
Practice Address - Country:US
Practice Address - Phone:214-382-1909
Practice Address - Fax:214-382-1903
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7821246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7821OtherSTATE OF TX