Provider Demographics
NPI:1790839629
Name:BALSHE, AYMAN A (DDS, MS)
Entity Type:Individual
Prefix:
First Name:AYMAN
Middle Name:A
Last Name:BALSHE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 E VIKING AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4655
Mailing Address - Country:US
Mailing Address - Phone:612-805-9505
Mailing Address - Fax:
Practice Address - Street 1:2115 E VIKING AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-4655
Practice Address - Country:US
Practice Address - Phone:612-805-9505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND123541223P0300X
CA570411223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN268487000Medicaid
MNP00372644Medicare ID - Type UnspecifiedRAILROAD
V11179Medicare UPIN
MN850000095Medicare PIN