Provider Demographics
NPI:1952612764
Name:BALLA, AMALIA (DDS)
Entity type:Individual
Prefix:DR
First Name:AMALIA
Middle Name:
Last Name:BALLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KNEELAND STREET
Mailing Address - Street 2:TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1529
Mailing Address - Country:US
Mailing Address - Phone:617-842-3800
Mailing Address - Fax:
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-842-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF10578122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist