Provider Demographics
NPI:1497858203
Name:JOSEPH D BALLENGER JR, DDS, PA
Entity Type:Organization
Organization Name:JOSEPH D BALLENGER JR, DDS, PA
Other - Org Name:COMSTOCK & BALLENGER LLS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ORAL & MAXILLONFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BALLENGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:208-452-4808
Mailing Address - Street 1:211 N WHITLEY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2704
Mailing Address - Country:US
Mailing Address - Phone:208-452-4808
Mailing Address - Fax:208-452-4816
Practice Address - Street 1:211 N WHITLEY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2704
Practice Address - Country:US
Practice Address - Phone:208-452-4808
Practice Address - Fax:208-452-4816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-2042-051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty