Provider Demographics
NPI:1972647956
Name:BALTZ, CHAD (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:BALTZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 JEFFERSON AVE
Mailing Address - Street 2:DENTAL SERVICE
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2127
Mailing Address - Country:US
Mailing Address - Phone:918-935-5511
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:DENTAL SERVICE
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:918-935-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031293L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist