Provider Demographics
NPI:1578668562
Name:BALLOU, SHELDON A (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHELDON
Middle Name:A
Last Name:BALLOU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42127
Mailing Address - Country:US
Mailing Address - Phone:270-773-3943
Mailing Address - Fax:270-773-3944
Practice Address - Street 1:203 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:KY
Practice Address - Zip Code:42127
Practice Address - Country:US
Practice Address - Phone:270-773-3943
Practice Address - Fax:270-773-3944
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61901096Medicaid