Healthcare Provider Details

I. General information

NPI: 1053803494
Provider Name (Legal Business Name): DILLON MATTHEW BALE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 DR MARTIN LUTHER KING ST N
SAINT PETERSBURG FL
33702-1108
US

IV. Provider business mailing address

7801 DR MARTIN LUTHER KING ST N
SAINT PETERSBURG FL
33702-1108
US

V. Phone/Fax

Practice location:
  • Phone: 727-525-4499
  • Fax:
Mailing address:
  • Phone: 727-525-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN23368
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: