Healthcare Provider Details

I. General information

NPI: 1952090789
Provider Name (Legal Business Name): LONDON BALES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 07/14/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 HARVEST HILLS DR
CARROLLTON MO
64633-2412
US

IV. Provider business mailing address

819 S BUSINESS HIGHWAY 13
LEXINGTON MO
64067-1515
US

V. Phone/Fax

Practice location:
  • Phone: 877-344-3572
  • Fax: 866-228-4492
Mailing address:
  • Phone: 660-667-0303
  • Fax: 660-251-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2025019620
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: