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General NPI Number Information
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NPI Number | 1871212738
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Entity Type | Organization
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Legal Business Name | PETER BALACKY DENTAL CORPORATION
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Dates
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Enumeration Date | 08/24/2022
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Last Update Date | 04/02/2024
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Provider Practice Location Address
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Address Line | 321 N LARCHMONT BLVD STE 613
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City | LOS ANGELES
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State | CA
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Zip | 90004-3051
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Country | US
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Telephone | 323-465-6451
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Fax |
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Provider Business Mailing Address
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Address Line | 321 N LARCHMONT BLVD STE 617
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City | LOS ANGELES
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State | CA
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Zip | 90004-6406
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Country | US
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Telephone | 323-465-6451
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PETER BALACKY
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Credential | DDS
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Telephone | 646-756-9450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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