Provider Demographics
NPI:1861554834
Name:MARY ANN BALDINO-GOMEZ D.D.S., S.C.
Entity type:Organization
Organization Name:MARY ANN BALDINO-GOMEZ D.D.S., S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDINO-GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BS, DDS
Authorized Official - Phone:847-265-9022
Mailing Address - Street 1:18759 W. WESTWOOD PL
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7432
Mailing Address - Country:US
Mailing Address - Phone:847-265-2782
Mailing Address - Fax:
Practice Address - Street 1:2450 GRASS LAKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5613
Practice Address - Country:US
Practice Address - Phone:847-265-9022
Practice Address - Fax:847-265-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190208361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty