Healthcare Provider Details

I. General information

NPI: 1962254128
Provider Name (Legal Business Name): BALACKY DENTAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N LARCHMONT BLVD STE 613
LOS ANGELES CA
90004-3051
US

IV. Provider business mailing address

2108 N ST STE 5621
SACRAMENTO CA
95816-5712
US

V. Phone/Fax

Practice location:
  • Phone: 646-756-9450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER BALACKY
Title or Position: PRESIDENT
Credential: DDS
Phone: 646-756-9450