Provider Demographics
NPI:1407187479
Name:JAMES IAN BALLOU, LLC
Entity Type:Organization
Organization Name:JAMES IAN BALLOU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-672-9279
Mailing Address - Street 1:2630 S CARRIER PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-5069
Mailing Address - Country:US
Mailing Address - Phone:972-660-5522
Mailing Address - Fax:972-660-5525
Practice Address - Street 1:2630 S CARRIER PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5069
Practice Address - Country:US
Practice Address - Phone:972-660-5522
Practice Address - Fax:972-660-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty