Provider Demographics
NPI:1578708087
Name:MARK R BALLENTINE DDS,PLLC
Entity Type:Organization
Organization Name:MARK R BALLENTINE DDS,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PLLC
Authorized Official - Phone:313-383-8960
Mailing Address - Street 1:9815 REECK RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1356
Mailing Address - Country:US
Mailing Address - Phone:313-383-8960
Mailing Address - Fax:313-383-7313
Practice Address - Street 1:9815 REECK RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1356
Practice Address - Country:US
Practice Address - Phone:313-383-8960
Practice Address - Fax:313-383-7313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID12983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty