Healthcare Provider Details

I. General information

NPI: 1134194673
Provider Name (Legal Business Name): GRACE BALYOUT KERR DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2752 ERIE AVE SUITE 1
CINCINNATI OH
45208-2207
US

IV. Provider business mailing address

2752 ERIE AVE SUITE 1
CINCINNATI OH
45208-2207
US

V. Phone/Fax

Practice location:
  • Phone: 513-533-4200
  • Fax: 513-533-4578
Mailing address:
  • Phone: 513-533-4200
  • Fax: 513-533-4578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19329
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: