Provider Demographics
NPI:1508485640
Name:BALOUCH DDS CORPORATION
Entity Type:Organization
Organization Name:BALOUCH DDS CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:BALOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-396-3999
Mailing Address - Street 1:1435 ANDENES DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1910
Mailing Address - Country:US
Mailing Address - Phone:818-396-3999
Mailing Address - Fax:
Practice Address - Street 1:8628 VAN NUYS BLVD # 200
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-2913
Practice Address - Country:US
Practice Address - Phone:818-895-1321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental