MEDICARE: FRED L BALLOU, DMD, PSC

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	1223G0001X	General Practice Dentistry	3905	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	532067	OTHER	KY	UNITED CONCORDIA

General Provider Information

NPI Number	:	1619972205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED L BALLOU, DMD, PSC

Provider Business Mailing Address
First Line	:	311 RADIO PARK DR
Second Line	:	STE B
City	:	RICHMOND
State	:	KY
Zip	:	40475-2399
Country	:	US
Telephone Number	:	859-623-3818
Fax Number	:	859-624-1061

Provider Business Practice Location Address
First Line	:	311 RADIO PARK DR
Second Line	:	STE B
City	:	RICHMOND
State	:	KY
Zip	:	40475-2399
Country	:	US
Telephone Number	:	859-623-3818
Fax Number	:	859-624-1061

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. FRED L BALLOU JR.
Credential	:	DMD
Telephone Number	:	859-623-3818

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	08/22/2020

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