MEDICARE: MR. PATRICK THOMAS BALLARD DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	9028	MN

General Provider Information

NPI Number	:	1578623773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PATRICK THOMAS BALLARD DDS

Provider Business Mailing Address
First Line	:	750 S PLAZA DR
Second Line	:	STE 316
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1505
Country	:	US
Telephone Number	:	651-452-5815
Fax Number	:	651-452-5378

Provider Business Practice Location Address
First Line	:	750 S PLAZA DR
Second Line	:	STE 316
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1505
Country	:	US
Telephone Number	:	651-452-5815
Fax Number	:	651-452-5378

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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