Provider Demographics
NPI:1255517850
Name:BALLET, LOURDES V (DDS)
Entity type:Individual
Prefix:MRS
First Name:LOURDES
Middle Name:V
Last Name:BALLET
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1857 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-3811
Mailing Address - Country:US
Mailing Address - Phone:321-283-2850
Mailing Address - Fax:386-951-4809
Practice Address - Street 1:1857 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-3811
Practice Address - Country:US
Practice Address - Phone:321-283-2850
Practice Address - Fax:386-951-4809
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN165201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL421713899OtherTAX IDENTIFICATION NUMBER