Provider Demographics
NPI:1790892511
Name:BALLANCE, LETITIA LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:LYNN
Last Name:BALLANCE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WAYNESVILLE PLZ
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-5765
Mailing Address - Country:US
Mailing Address - Phone:828-452-5656
Mailing Address - Fax:828-452-5680
Practice Address - Street 1:205 WAYNESVILLE PLZ
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786-5765
Practice Address - Country:US
Practice Address - Phone:828-452-5656
Practice Address - Fax:828-452-5680
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC64851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
9005COtherBLUE CROSS BLUE SHIELD NC
NC89-9005CMedicaid