Provider Demographics
NPI:1902125578
Name:BALTZ, JUSTIN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:BALTZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3574 S TOWER RD
Mailing Address - Street 2:STE B
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-3561
Mailing Address - Country:US
Mailing Address - Phone:303-617-9100
Mailing Address - Fax:303-617-9198
Practice Address - Street 1:3574 S TOWER RD
Practice Address - Street 2:STE B
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-3561
Practice Address - Country:US
Practice Address - Phone:303-617-9100
Practice Address - Fax:303-617-9198
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI364295Medicaid