Provider Demographics
NPI:1568979813
Name:BALANI, DEEPAK (DMD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:
Last Name:BALANI
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 MONTVALE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-4692
Mailing Address - Country:US
Mailing Address - Phone:781-999-1817
Mailing Address - Fax:
Practice Address - Street 1:318 MONTVALE AVE STE 100
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-4692
Practice Address - Country:US
Practice Address - Phone:781-999-1817
Practice Address - Fax:857-201-4022
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN185085122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist