Healthcare Provider Details

I. General information

NPI: 1720394794
Provider Name (Legal Business Name): BANAFSHEH M BALL D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15245 SHADY GROVE RD STE 260
ROCKVILLE MD
20850-3222
US

IV. Provider business mailing address

15245 SHADY GROVE RD STE 260
ROCKVILLE MD
20850-3222
US

V. Phone/Fax

Practice location:
  • Phone: 240-848-7074
  • Fax: 240-848-7075
Mailing address:
  • Phone: 240-848-7074
  • Fax: 240-848-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14676
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: