Healthcare Provider Details

I. General information

NPI: 1851446157
Provider Name (Legal Business Name): STEVEN MARK BALLOCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEBRON AVE SUITE 112
GLASTONBURY CT
06033-2176
US

IV. Provider business mailing address

300 HEBRON AVE SUITE 112
GLASTONBURY CT
06033-2176
US

V. Phone/Fax

Practice location:
  • Phone: 860-659-8660
  • Fax: 860-633-6229
Mailing address:
  • Phone: 860-659-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5772
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: