Provider Demographics
NPI:1053635458
Name:BALLANI, MOHANAD
Entity Type:Individual
Prefix:
First Name:MOHANAD
Middle Name:
Last Name:BALLANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:
Practice Address - Street 1:G3538 MILLER RD
Practice Address - Street 2:STE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1271
Practice Address - Country:US
Practice Address - Phone:810-424-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010200631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice