Provider Demographics
NPI:1558481937
Name:BALLAST, MARTINA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MARTINA
Middle Name:
Last Name:BALLAST
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 1:7 SLOCUM AVE.
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-871-3581
Mailing Address - Fax:212-543-9769
Practice Address - Street 1:563 W 184TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-4128
Practice Address - Country:US
Practice Address - Phone:212-543-3000
Practice Address - Fax:212-543-9769
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046143122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01643787Medicaid