Provider Demographics
NPI:1356504088
Name:BALL, THOMAS BOAKE
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BOAKE
Last Name:BALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-2612
Mailing Address - Country:US
Mailing Address - Phone:956-787-3821
Mailing Address - Fax:
Practice Address - Street 1:212 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-2612
Practice Address - Country:US
Practice Address - Phone:956-787-3821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14016122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist