Provider Demographics
NPI:1487738381
Name:BALZANO, GARY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:BALZANO
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 1:305 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-3873
Mailing Address - Country:US
Mailing Address - Phone:505-461-2400
Mailing Address - Fax:505-461-2400
Practice Address - Street 1:305 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3873
Practice Address - Country:US
Practice Address - Phone:505-461-2400
Practice Address - Fax:505-461-2400
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM13921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice