Provider Demographics
NPI:1922482397
Name:BALLO, NASEM
Entity Type:Individual
Prefix:
First Name:NASEM
Middle Name:
Last Name:BALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CLARK ST
Mailing Address - Street 2:STE 600
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4712
Mailing Address - Country:US
Mailing Address - Phone:312-274-4526
Mailing Address - Fax:
Practice Address - Street 1:3890 DIXIE HWY
Practice Address - Street 2:SUITE #1A
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-4201
Practice Address - Country:US
Practice Address - Phone:989-777-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021669122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist