Provider Demographics
NPI:1336364025
Name:BALVICH, JORDAN J (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:J
Last Name:BALVICH
Suffix:
Gender:M
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:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-0027
Mailing Address - Country:US
Mailing Address - Phone:219-866-8110
Mailing Address - Fax:219-866-8332
Practice Address - Street 1:129 N VAN RENSSELAER ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2651
Practice Address - Country:US
Practice Address - Phone:219-866-8110
Practice Address - Fax:219-866-8332
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009450A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist