=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205989357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD JOSEPH BALLAS D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24700 CENTER RIDGE RD
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-871-0550
-----------------------------------------------------
Fax | 440-871-0550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24700 CENTER RIDGE RD
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-871-0550
-----------------------------------------------------
Fax | 440-871-0550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30013031
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------