Healthcare Provider Details

I. General information

NPI: 1578668562
Provider Name (Legal Business Name): SHELDON A BALLOU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S DIXIE HWY
CAVE CITY KY
42127
US

IV. Provider business mailing address

203 S DIXIE HWY
CAVE CITY KY
42127
US

V. Phone/Fax

Practice location:
  • Phone: 270-773-3943
  • Fax: 270-773-3944
Mailing address:
  • Phone: 270-773-3943
  • Fax: 270-773-3944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6425
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: