Provider Demographics
NPI:1750580288
Name:BALDERSTON, CARREL D JR (DDS)
Entity type:Individual
Prefix:
First Name:CARREL
Middle Name:D
Last Name:BALDERSTON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:DEAN
Other - Last Name:BALDERSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1074 EAST AVE STE U
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1052
Mailing Address - Country:US
Mailing Address - Phone:530-342-8580
Mailing Address - Fax:530-873-2104
Practice Address - Street 1:1074 EAST AVE STE U
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1052
Practice Address - Country:US
Practice Address - Phone:530-342-8580
Practice Address - Fax:530-873-2104
Is Sole Proprietor?:No
Enumeration Date:2007-07-14
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42119122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist