MEDICARE: RONALD STEVEN BALLBACK 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	24743	CA

General Provider Information

NPI Number	:	1851500896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD STEVEN BALLBACK DDS

Provider Business Mailing Address
First Line	:	217 MARINE AVE STE A
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92662-1289
Country	:	US
Telephone Number	:	949-673-6720
Fax Number	:	949-673-6682

Provider Business Practice Location Address
First Line	:	217 MARINE AVE STE A
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92662-1289
Country	:	US
Telephone Number	:	949-673-6720
Fax Number	:	949-673-6682

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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