Provider Demographics
NPI:1235488842
Name:BALLAS, NATALIE JACKSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:JACKSON
Last Name:BALLAS
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 1:300 N HOLLY STREET
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013
Mailing Address - Country:US
Mailing Address - Phone:503-266-1117
Mailing Address - Fax:
Practice Address - Street 1:300 N HOLLY STREET
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013
Practice Address - Country:US
Practice Address - Phone:503-266-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9856122300000X
WV40101223G0001X
MD152001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice