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General NPI Number Information
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NPI Number | 1639303860
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Entity Type | Individual
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Provider Name | TOMAS JOSE BALLESTEROS IV DMD
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Gender | Male
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Dates
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Enumeration Date | 05/01/2009
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Last Update Date | 05/01/2009
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Provider Practice Location Address
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Address Line | 64 S 23RD ST
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City | KENILWORTH
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State | NJ
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Zip | 07033-1630
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Country | US
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Telephone | 339-221-1551
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Fax |
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Provider Business Mailing Address
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Address Line | 64 S 23RD ST
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City | KENILWORTH
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State | NJ
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Zip | 07033-1630
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Country | US
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Telephone | 339-221-1551
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 50 054337
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License Number State | NY
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