Healthcare Provider Details

I. General information

NPI: 1063564813
Provider Name (Legal Business Name): SHELDON A. BALLOU, DMD, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S DIXIE HWY
CAVE CITY KY
42127-8866
US

IV. Provider business mailing address

203 S DIXIE HWY
CAVE CITY KY
42127-8866
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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6425
License Number StateKY

VIII. Authorized Official

Name: DR. SHELDON ARCH BALLOU
Title or Position: PRESIDENT
Credential: DMD
Phone: 270-773-3943