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NPI Code Detail

MEDICARE: BALLANCE & DEROSE DDS PA

MEDICARE: BALLANCE & DEROSE DDS PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1018CYOTHERBLUE CROSS BLUE SHIELD NC
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1053344630
Entity Type Code : Organization
Provider Name (Legal Business Name) : BALLANCE & DEROSE DDS PA
Provider Business Mailing Address
First Line : 2041 SILAS CREEK PKWY
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27103-5147
Country : US
Telephone Number : 336-777-0303
Fax Number : 336-777-3448
Provider Business Practice Location Address
First Line : 900 SUMMIT AVE
Second Line :
City : GREENSBORO
State : NC
Zip : 27405-7918
Country : US
Telephone Number : 336-370-1112
Fax Number : 336-544-0739
Authorized Official
Title or Position : OWNER
Name : DR. MICHAEL ANTHONY DEROSE
Credential : DDS
Telephone Number : 336-777-0303
Provider Enumeration Date : 07/08/2006
Last Update Date : 08/22/2020

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Directions to “BALLANCE & DEROSE DDS PA ” Practice Location

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