Provider Demographics
NPI:1679630206
Name:BALLARD, JEFFERY B (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:B
Last Name:BALLARD
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 1:707 WHITLOCK AVENUE
Mailing Address - Street 2:SUITE C 25
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:770-422-7727
Mailing Address - Fax:770-427-8009
Practice Address - Street 1:707 WHITLOCK AVENUE
Practice Address - Street 2:SUITE C 25
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:770-422-7727
Practice Address - Fax:770-427-8009
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA982949OtherUNITED CONCORDIA