Provider Demographics
NPI:1053322438
Name:KORDAB, NADA BALLOUT (DDS)
Entity Type:Individual
Prefix:DR
First Name:NADA
Middle Name:BALLOUT
Last Name:KORDAB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18522 CANOE BRK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-1641
Mailing Address - Country:US
Mailing Address - Phone:901-246-7560
Mailing Address - Fax:
Practice Address - Street 1:18522 CANOE BRK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-1641
Practice Address - Country:US
Practice Address - Phone:901-246-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8545122300000X
TX30089122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441013Medicaid