=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922956572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN DENTAL SMILES OF WELLINGTON PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2026
-----------------------------------------------------
Last Update Date | 03/19/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13860 WELLINGTON TRCE STE 14
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-8590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-791-4440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13860 WELLINGTON TRCE STE 14
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-8590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-791-4440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | KURT O BALLY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 954-806-6229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------