MEDICARE: ELLEN VANDERGUST BALLARD 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	1668	NM

General Provider Information

NPI Number	:	1649452129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN VANDERGUST BALLARD DDS

Provider Business Mailing Address
First Line	:	111 LONGVIEW
Second Line	:	SUITE B-3
City	:	WHITE ROCK
State	:	NM
Zip	:	87544
Country	:	US
Telephone Number	:	505-672-2020
Fax Number	:	505-672-2020

Provider Business Practice Location Address
First Line	:	111 LONGVIEW
Second Line	:	SUITE B-3
City	:	WHITE ROCK
State	:	NM
Zip	:	87544
Country	:	US
Telephone Number	:	505-672-2020
Fax Number	:	505-672-2020

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

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	11/27/2007

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