Provider Demographics
NPI:1629290283
Name:WILDWIND DENTAL
Entity Type:Organization
Organization Name:WILDWIND DENTAL
Other - Org Name:ELLEN BALLARD DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT WILDWIND DENTAL
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:VANDERGUST
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-672-2020
Mailing Address - Street 1:203 RIO BRAVO
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-920-1065
Mailing Address - Fax:
Practice Address - Street 1:111 LONGVIEW DRIVE
Practice Address - Street 2:SUITE B3
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-672-2020
Practice Address - Fax:505-672-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty