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General NPI Number Information
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NPI Number | 1578708087
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Entity Type | Organization
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Legal Business Name | MARK R BALLENTINE DDS,PLLC
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Dates
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Enumeration Date | 12/12/2008
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Last Update Date | 12/12/2008
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Provider Practice Location Address
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Address Line | 9815 REECK RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-1356
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Country | US
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Telephone | 313-383-8960
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Fax | 313-383-7313
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Provider Business Mailing Address
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Address Line | 9815 REECK RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-1356
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Country | US
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Telephone | 313-383-8960
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Fax | 313-383-7313
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Authorized Official
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Title or Position | SOLE OWNER
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Name | DR. MARK ROBERT BALLENTINE
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Credential | DDS,PLLC
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Telephone | 313-383-8960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D12983
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License Number State | MI
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