Provider Demographics
NPI:1780728048
Name:BALLENTINE, STEPHANIE EARLINE (DDS PA)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:EARLINE
Last Name:BALLENTINE
Suffix:
Gender:F
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 MATHESON AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1670
Mailing Address - Country:US
Mailing Address - Phone:704-334-6907
Mailing Address - Fax:704-376-4773
Practice Address - Street 1:1315 MATHESON AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-1670
Practice Address - Country:US
Practice Address - Phone:704-334-6907
Practice Address - Fax:704-376-4773
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC48311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990381Medicaid