Healthcare Provider Details

I. General information

NPI: 1154486579
Provider Name (Legal Business Name): DONALD B. BALHOFF D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909-E AMBASSADOR CAFFERY PKWY.
LAFAYETTE LA
70503-5236
US

IV. Provider business mailing address

3909-E AMBASSADOR CAFFERY PKWY.
LAFAYETTE LA
70503-5236
US

V. Phone/Fax

Practice location:
  • Phone: 337-761-7070
  • Fax: 337-761-7171
Mailing address:
  • Phone: 337-761-7070
  • Fax: 337-761-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5167
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: