Provider Demographics
NPI:1891869293
Name:BALLIN, ANDREW RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:RICHARD
Last Name:BALLIN
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 1:6053 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-2558
Mailing Address - Country:US
Mailing Address - Phone:612-866-3665
Mailing Address - Fax:612-866-9461
Practice Address - Street 1:6053 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-2558
Practice Address - Country:US
Practice Address - Phone:612-866-3665
Practice Address - Fax:612-866-9461
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND79321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN74230BAOtherBLUE CROSS BLUE SHIELD
MN8614783OtherMEDICA MEDICAL
MN8614783OtherMEDICA MEDICAL