Healthcare Provider Details

I. General information

NPI: 1548097124
Provider Name (Legal Business Name): BALA ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BELMONT AVE STE 414
BALA CYNWYD PA
19004-1607
US

IV. Provider business mailing address

500 CHAPMAN ST FL 1
CANTON MA
02021-2093
US

V. Phone/Fax

Practice location:
  • Phone: 610-617-0700
  • Fax:
Mailing address:
  • Phone: 781-562-0457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHRISTINE SHAW
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 781-562-0457