Provider Demographics
NPI:1861847345
Name:BALLARD FAMILY DENTISTRY IN BOYD
Entity Type:Organization
Organization Name:BALLARD FAMILY DENTISTRY IN BOYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPPETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-367-6453
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:BOYD
Mailing Address - State:TX
Mailing Address - Zip Code:76023
Mailing Address - Country:US
Mailing Address - Phone:940-433-8545
Mailing Address - Fax:940-433-0155
Practice Address - Street 1:400 W. ROCK ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BOYD
Practice Address - State:TX
Practice Address - Zip Code:76023
Practice Address - Country:US
Practice Address - Phone:940-433-8545
Practice Address - Fax:940-433-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21511122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty