=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558186932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALLPARK FAMILY DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2024
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 POWELL DR STE 5
-----------------------------------------------------
City | DUNDEE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48131-8645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-334-5574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 RISDON TRL S
-----------------------------------------------------
City | SALINE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48176-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-334-5574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CORY ALLEN BALL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 616-334-5574
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------