Provider Demographics
NPI:1528381357
Name:BALLARD, MARY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:BALLARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 E LAFAYETTE PL UNIT 1901
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1591
Mailing Address - Country:US
Mailing Address - Phone:703-772-4355
Mailing Address - Fax:
Practice Address - Street 1:2860 S GREEN BAY RD STE 104
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4962
Practice Address - Country:US
Practice Address - Phone:262-833-7996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7206-151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery