Provider Demographics
NPI:1588187819
Name:BALANCED DENTAL
Entity Type:Organization
Organization Name:BALANCED DENTAL
Other - Org Name:BALANCED DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CRESTON
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:772-247-2407
Mailing Address - Street 1:900 SE OCEAN BLVD STE 110B
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3503
Mailing Address - Country:US
Mailing Address - Phone:772-247-2407
Mailing Address - Fax:
Practice Address - Street 1:900 SE OCEAN BLVD STE 110B
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3503
Practice Address - Country:US
Practice Address - Phone:954-818-6102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID C JACKSON DMD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-18
Last Update Date:2017-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental