Healthcare Provider Details

I. General information

NPI: 1174514830
Provider Name (Legal Business Name): ALEXANDRE BALACI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 TUCK ST
LEBANON PA
17042-7477
US

IV. Provider business mailing address

860 TUCK ST
LEBANON PA
17042-7477
US

V. Phone/Fax

Practice location:
  • Phone: 717-273-6745
  • Fax: 717-273-0009
Mailing address:
  • Phone: 717-273-6745
  • Fax: 717-273-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS028132-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: