Provider Demographics
NPI:1598811499
Name:BRIAN A. BALDA, D.M.D.,P.C.
Entity Type:Organization
Organization Name:BRIAN A. BALDA, D.M.D.,P.C.
Other - Org Name:BALDA DENTAL OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALDA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-342-3411
Mailing Address - Street 1:401 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3442
Mailing Address - Country:US
Mailing Address - Phone:217-342-3411
Mailing Address - Fax:217-347-6551
Practice Address - Street 1:401 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-3442
Practice Address - Country:US
Practice Address - Phone:217-342-3411
Practice Address - Fax:217-347-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0204011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty