Provider Demographics
NPI:1619972205
Name:FRED L BALLOU, DMD, PSC
Entity Type:Organization
Organization Name:FRED L BALLOU, DMD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:L
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-623-3818
Mailing Address - Street 1:311 RADIO PARK DR
Mailing Address - Street 2:STE B
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2399
Mailing Address - Country:US
Mailing Address - Phone:859-623-3818
Mailing Address - Fax:859-624-1061
Practice Address - Street 1:311 RADIO PARK DR
Practice Address - Street 2:STE B
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2399
Practice Address - Country:US
Practice Address - Phone:859-623-3818
Practice Address - Fax:859-624-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY532067OtherUNITED CONCORDIA