Provider Demographics
NPI:1770078719
Name:BALBUENA TAPIA, ERICA (DMD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:BALBUENA TAPIA
Suffix:
Gender:F
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:PO BOX 113
Mailing Address - Street 2:
Mailing Address - City:FALKLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27827-0113
Mailing Address - Country:US
Mailing Address - Phone:252-227-3187
Mailing Address - Fax:
Practice Address - Street 1:120 W MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4906
Practice Address - Country:US
Practice Address - Phone:252-940-0602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11091OtherDENTAL LICENSE