Provider Demographics
NPI:1598873341
Name:BALU, RAVI (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:
Last Name:BALU
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 1:1952 UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-3858
Mailing Address - Country:US
Mailing Address - Phone:724-628-9340
Mailing Address - Fax:724-628-4090
Practice Address - Street 1:1952 UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-3858
Practice Address - Country:US
Practice Address - Phone:724-628-9340
Practice Address - Fax:724-628-4090
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS07029L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice