Provider Demographics
NPI:1487829636
Name:SHELDON A. BALLOU DMD,P.S.C.
Entity Type:Organization
Organization Name:SHELDON A. BALLOU DMD,P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELDON
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-773-3943
Mailing Address - Street 1:203 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42127-8866
Mailing Address - Country:US
Mailing Address - Phone:270-773-3943
Mailing Address - Fax:270-773-3944
Practice Address - Street 1:203 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:KY
Practice Address - Zip Code:42127-8866
Practice Address - Country:US
Practice Address - Phone:270-773-3943
Practice Address - Fax:270-773-3944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY64251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45003779Medicaid