Provider Demographics
NPI:1740302389
Name:BALLINGER, MATTHEW MARK (DMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MARK
Last Name:BALLINGER
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 1:200 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6551
Mailing Address - Country:US
Mailing Address - Phone:443-610-7591
Mailing Address - Fax:
Practice Address - Street 1:200 ELM ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6551
Practice Address - Country:US
Practice Address - Phone:443-610-7591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD126051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice