Provider Demographics
NPI:1821448036
Name:BALTA FALLS, LLC
Entity Type:Organization
Organization Name:BALTA FALLS, LLC
Other - Org Name:MOUNTAIN VISTA DENTAL CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-868-1864
Mailing Address - Street 1:1945 S ARCO DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-3017
Mailing Address - Country:US
Mailing Address - Phone:480-868-1864
Mailing Address - Fax:
Practice Address - Street 1:3125 W HUNT HWY
Practice Address - Street 2:UNIT 101
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85142-9315
Practice Address - Country:US
Practice Address - Phone:480-868-1864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRILEAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0093751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty