Provider Demographics
NPI:1013270172
Name:BALK, LISEL (DMD)
Entity Type:Individual
Prefix:
First Name:LISEL
Middle Name:
Last Name:BALK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SOUTH ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 STANIFORD ST STE 303
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2542
Practice Address - Country:US
Practice Address - Phone:617-523-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857120122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist