Provider Demographics
NPI:1457546798
Name:JOSEPH D. BALLENGER JR. DDS PA
Entity Type:Organization
Organization Name:JOSEPH D. BALLENGER JR. DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BALLENGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS PA
Authorized Official - Phone:208-467-1227
Mailing Address - Street 1:339 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2856
Mailing Address - Country:US
Mailing Address - Phone:208-467-1227
Mailing Address - Fax:208-467-1299
Practice Address - Street 1:339 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2856
Practice Address - Country:US
Practice Address - Phone:208-467-1227
Practice Address - Fax:208-467-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-2042-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0026640000Medicaid
ID805475200Medicaid
ID0026640000Medicaid
ID805475200Medicaid