Provider Demographics
NPI:1821319450
Name:BALANEY, SAMIR (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:
Last Name:BALANEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 SOUTH STATE ST
Mailing Address - Street 2:#1902
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1932
Mailing Address - Country:US
Mailing Address - Phone:630-915-4046
Mailing Address - Fax:
Practice Address - Street 1:6301 WEST CERMAK
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2368
Practice Address - Country:US
Practice Address - Phone:708-956-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028291122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist