Healthcare Provider Details

I. General information

NPI: 1992887392
Provider Name (Legal Business Name): JOHN W BALABAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 103, SUPPLY ST
GARY WV
24836
US

IV. Provider business mailing address

PO BOX 108
GREENSBORO PA
15338-0108
US

V. Phone/Fax

Practice location:
  • Phone: 304-448-2101
  • Fax: 304-448-3217
Mailing address:
  • Phone: 724-943-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1793
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: