Provider Demographics
NPI:1851501423
Name:BALES, LAUREN JEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:JEAN
Last Name:BALES
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:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-1359
Mailing Address - Country:US
Mailing Address - Phone:417-683-4831
Mailing Address - Fax:417-683-1602
Practice Address - Street 1:1604 C NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-0000
Practice Address - Country:US
Practice Address - Phone:417-926-1209
Practice Address - Fax:417-683-1602
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030012881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1851501423Medicaid