Provider Demographics
NPI:1851446157
Name:BALLOCH, STEVEN MARK (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:MARK
Last Name:BALLOCH
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 1:300 HEBRON AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2176
Mailing Address - Country:US
Mailing Address - Phone:860-659-3044
Mailing Address - Fax:
Practice Address - Street 1:300 HEBRON AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2176
Practice Address - Country:US
Practice Address - Phone:860-659-8660
Practice Address - Fax:860-633-6229
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT57721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice