Provider Demographics
NPI:1346364411
Name:BALLA, LESZEK ADAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESZEK
Middle Name:ADAM
Last Name:BALLA
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 1:3638 CRAIN ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2352
Mailing Address - Country:US
Mailing Address - Phone:847-329-0972
Mailing Address - Fax:
Practice Address - Street 1:1701 S 1ST AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-2442
Practice Address - Country:US
Practice Address - Phone:708-450-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0170661223G0001X, 122300000X
WI2604-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice