MEDICARE: DR. MARK BALONEK DDS

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
1	1223G0001X	General Practice Dentistry	041559	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041559	OTHER	NY	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1326198565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BALONEK DDS

Provider Business Mailing Address
First Line	:	513 BEAHAN RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14624-3403
Country	:	US
Telephone Number	:	585-426-3050
Fax Number	:

Provider Business Practice Location Address
First Line	:	513 BEAHAN RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14624-3403
Country	:	US
Telephone Number	:	585-426-3050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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