Provider Demographics
NPI:1093885139
Name:BALLESTEROS, JAIME (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:BALLESTEROS
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 1:621 PLAINFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5385
Mailing Address - Country:US
Mailing Address - Phone:630-920-8582
Mailing Address - Fax:630-920-8602
Practice Address - Street 1:621 PLAINFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5385
Practice Address - Country:US
Practice Address - Phone:630-920-8582
Practice Address - Fax:630-920-8602
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist