Provider Demographics
NPI:1124139548
Name:BALLARD, GRAYDON L III (DMD)
Entity type:Individual
Prefix:DR
First Name:GRAYDON
Middle Name:L
Last Name:BALLARD
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 N MERAMEC AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3758
Mailing Address - Country:US
Mailing Address - Phone:314-727-4900
Mailing Address - Fax:314-727-9888
Practice Address - Street 1:168 N MERAMEC AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3758
Practice Address - Country:US
Practice Address - Phone:314-727-4900
Practice Address - Fax:314-727-9888
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0144161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice