Provider Demographics
NPI:1073838561
Name:BALYAN, SUPRITI (DDS)
Entity Type:Individual
Prefix:
First Name:SUPRITI
Middle Name:
Last Name:BALYAN
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 1:2145 ROSWELL RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-0821
Mailing Address - Country:US
Mailing Address - Phone:770-565-1010
Mailing Address - Fax:770-565-1037
Practice Address - Street 1:2145 ROSWELL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-0821
Practice Address - Country:US
Practice Address - Phone:770-565-1010
Practice Address - Fax:770-565-1037
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011733122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist