Provider Demographics
NPI:1578662375
Name:BALLARD, RICHARD A (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BALLARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1745
Mailing Address - Country:US
Mailing Address - Phone:208-263-4122
Mailing Address - Fax:
Practice Address - Street 1:1221 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1745
Practice Address - Country:US
Practice Address - Phone:208-263-4122
Practice Address - Fax:208-263-2082
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3867OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics