Provider Demographics
NPI:1497263685
Name:1500 GRANT BLVD DENTISTRY, PLLC
Entity Type:Organization
Organization Name:1500 GRANT BLVD DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARUN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALAKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-472-3414
Mailing Address - Street 1:1500 GRANT BLVD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-3014
Mailing Address - Country:US
Mailing Address - Phone:315-472-3414
Mailing Address - Fax:315-472-4320
Practice Address - Street 1:1500 GRANT BLVD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-3014
Practice Address - Country:US
Practice Address - Phone:315-472-3414
Practice Address - Fax:315-472-4320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051141261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental