Healthcare Provider Details

I. General information

NPI: 1629259205
Provider Name (Legal Business Name): JOHN WALTER BALLRICK D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2007
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28885 CENTER RIDGE RD STE 203
WESTLAKE OH
44145-5275
US

IV. Provider business mailing address

28885 CENTER RIDGE RD STE 203
WESTLAKE OH
44145-5275
US

V. Phone/Fax

Practice location:
  • Phone: 440-835-6113
  • Fax: 440-835-4344
Mailing address:
  • Phone: 440-835-6113
  • Fax: 440-331-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.022156
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: