Provider Demographics
NPI:1639303860
Name:BALLESTEROS, TOMAS JOSE IV (DMD)
Entity Type:Individual
Prefix:DR
First Name:TOMAS
Middle Name:JOSE
Last Name:BALLESTEROS
Suffix:IV
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 1:64 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-1630
Mailing Address - Country:US
Mailing Address - Phone:339-221-1551
Mailing Address - Fax:
Practice Address - Street 1:64 S 23RD ST
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1630
Practice Address - Country:US
Practice Address - Phone:339-221-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50 054337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist