Provider Demographics
NPI:1053873851
Name:DE LA FUENTE BALBOA, JAVIER (DMD)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:DE LA FUENTE BALBOA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 SW 62ND PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-2170
Mailing Address - Country:US
Mailing Address - Phone:786-234-4280
Mailing Address - Fax:
Practice Address - Street 1:6060 SW 62ND PL
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-2170
Practice Address - Country:US
Practice Address - Phone:786-234-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN244111223E0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223E0200XDental ProvidersDentistEndodontics