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General NPI Number Information
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NPI Number | 1346364411
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Entity Type | Individual
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Provider Name | LESZEK ADAM BALLA D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 04/21/2021
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Provider Practice Location Address
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Address Line | 1701 S 1ST AVE SUITE 102
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City | MAYWOOD
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State | IL
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Zip | 60153-2442
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Country | US
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Telephone | 708-450-5300
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Fax |
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Provider Business Mailing Address
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Address Line | 3638 CRAIN ST
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City | SKOKIE
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State | IL
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Zip | 60076-2352
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Country | US
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Telephone | 847-329-0972
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019-017066
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2604-015
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019-017066
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License Number State | IL
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