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General NPI Number Information
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NPI Number | 1619972205
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Entity Type | Organization
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Legal Business Name | FRED L BALLOU, DMD, PSC
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Dates
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Enumeration Date | 06/20/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 311 RADIO PARK DR STE B
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City | RICHMOND
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State | KY
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Zip | 40475-2399
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Country | US
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Telephone | 859-623-3818
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Fax | 859-624-1061
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Provider Business Mailing Address
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Address Line | 311 RADIO PARK DR STE B
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City | RICHMOND
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State | KY
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Zip | 40475-2399
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Country | US
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Telephone | 859-623-3818
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Fax | 859-624-1061
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. FRED L BALLOU JR.
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Credential | DMD
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Telephone | 859-623-3818
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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 | 3905
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License Number State | KY
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