Provider Demographics
NPI:1477396851
Name:BALAZE DENTAL GROUP
Entity type:Organization
Organization Name:BALAZE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:BALAZE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-275-4491
Mailing Address - Street 1:250 N ROBERTSON BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1789
Mailing Address - Country:US
Mailing Address - Phone:310-275-4491
Mailing Address - Fax:
Practice Address - Street 1:250 N ROBERTSON BLVD STE 401
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1789
Practice Address - Country:US
Practice Address - Phone:310-275-4491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-14
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental