Provider Demographics
NPI:1164881926
Name:BALACKY, PETER ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ANTHONY
Last Name:BALACKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15332 ANTIOCH ST STE 410
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3603
Mailing Address - Country:US
Mailing Address - Phone:424-322-0405
Mailing Address - Fax:
Practice Address - Street 1:321 N LARCHMONT BLVD STE 613
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3051
Practice Address - Country:US
Practice Address - Phone:323-465-6451
Practice Address - Fax:323-465-6446
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN03707204E00000X
WY1666204E00000X
AZD012069204E00000X
IDD-5590204E00000X
ORD11935204E00000X
NJ22DI03009300204E00000X
NMDB-2024-0028204E00000X
IL19034729204E00000X
VT016.0134252204E00000X
KY11062204E00000X
NY061045204E00000X
CODEN.00205881204E00000X
HIDT-3154204E00000X
VA401418811204E00000X
CA107091204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty