Provider Demographics
NPI:1881059673
Name:BALLASDENTAL
Entity type:Organization
Organization Name:BALLASDENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-5544
Mailing Address - Street 1:2821 N BALLAS RD STE 140
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2377
Mailing Address - Country:US
Mailing Address - Phone:314-432-5544
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD STE 140
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2377
Practice Address - Country:US
Practice Address - Phone:314-432-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11564284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOBALLASDENT2015Medicare UPIN