Healthcare Provider Details

I. General information

NPI: 1891869293
Provider Name (Legal Business Name): ANDREW RICHARD BALLIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6053 NICOLLET AVE
MINNEAPOLIS MN
55419-2558
US

IV. Provider business mailing address

6053 NICOLLET AVE
MINNEAPOLIS MN
55419-2558
US

V. Phone/Fax

Practice location:
  • Phone: 612-866-3665
  • Fax: 612-866-9461
Mailing address:
  • Phone: 612-866-3665
  • Fax: 612-866-9461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD7932
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: