Provider Demographics
NPI:1033894662
Name:CEBALLOS, JHON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JHON
Middle Name:
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:399 CONGRESS ST APT 404
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-2574
Mailing Address - Country:US
Mailing Address - Phone:305-748-7703
Mailing Address - Fax:
Practice Address - Street 1:119 WINDSOR ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3647
Practice Address - Country:US
Practice Address - Phone:617-665-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL157521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice