Healthcare Provider Details

I. General information

NPI: 1497858203
Provider Name (Legal Business Name): JOSEPH D BALLENGER JR, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N WHITLEY DR SUITE 3
FRUITLAND ID
83619-2704
US

IV. Provider business mailing address

211 N WHITLEY DR SUITE 3
FRUITLAND ID
83619-2704
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-4808
  • Fax: 208-452-4816
Mailing address:
  • Phone: 208-452-4808
  • Fax: 208-452-4816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-2042-05
License Number StateID

VIII. Authorized Official

Name: JOSEPH D BALLENGER JR.
Title or Position: ORAL & MAXILLONFACIAL SURGEON
Credential: DDS, PA
Phone: 208-452-4808