Provider Demographics
NPI:1356578256
Name:BALLER, RYAN TIMOTHY (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:TIMOTHY
Last Name:BALLER
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 1:1021 NEBRASKA ST
Mailing Address - Street 2:P.O. BOX 5410
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102
Mailing Address - Country:US
Mailing Address - Phone:712-202-1006
Mailing Address - Fax:
Practice Address - Street 1:4100 MORNINGSIDE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-2974
Practice Address - Country:US
Practice Address - Phone:712-274-2038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA086261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice