Provider Demographics
NPI:1619987922
Name:BALCERAK, RICHARD JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:BALCERAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E 1ST ST
Mailing Address - Street 2:STE 103
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521
Mailing Address - Country:US
Mailing Address - Phone:630-789-8070
Mailing Address - Fax:630-789-8071
Practice Address - Street 1:105 E 1ST ST
Practice Address - Street 2:STE 103
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-789-8070
Practice Address - Fax:630-789-8071
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
K02516Medicare ID - Type Unspecified
K02514Medicare ID - Type Unspecified
K02515Medicare ID - Type Unspecified
T38789Medicare UPIN