Provider Demographics
NPI:1861034076
Name:BALLARD, TIFFANY (LDH)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2673 W 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6948
Mailing Address - Country:US
Mailing Address - Phone:317-629-9014
Mailing Address - Fax:
Practice Address - Street 1:3229 BROADWAY STE 115
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1040
Practice Address - Country:US
Practice Address - Phone:219-806-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13007024A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist