MEDICARE: CHARLES CHRIS BALLARD D.D.S.

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	207L00000X	Anesthesiology Physician	15124	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	760538820	OTHER	TX	TAX ID

General Provider Information

NPI Number	:	1538176359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES CHRIS BALLARD D.D.S.

Provider Business Mailing Address
First Line	:	2506 AUTUMN GARDEN CT
Second Line	:
City	:	KINGWOOD
State	:	TX
Zip	:	77345-2233
Country	:	US
Telephone Number	:	281-360-6019
Fax Number	:	281-361-0762

Provider Business Practice Location Address
First Line	:	2506 AUTUMN GARDEN CT
Second Line	:
City	:	KINGWOOD
State	:	TX
Zip	:	77345-2233
Country	:	US
Telephone Number	:	281-360-6019
Fax Number	:	281-361-0762

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	04/13/2009

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