Healthcare Provider Details

I. General information

NPI: 1861034076
Provider Name (Legal Business Name): TIFFANY BALLARD LDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3229 BROADWAY STE 115
GARY IN
46409-1040
US

IV. Provider business mailing address

2673 W 86TH AVE
MERRILLVILLE IN
46410-6948
US

V. Phone/Fax

Practice location:
  • Phone: 219-806-3000
  • Fax:
Mailing address:
  • Phone: 317-629-9014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13007024A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: