Provider Demographics
NPI:1316968340
Name:BALACH, GEORGE MICHAEL I (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MICHAEL
Last Name:BALACH
Suffix:I
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2459
Mailing Address - Country:US
Mailing Address - Phone:218-624-5965
Mailing Address - Fax:218-624-4628
Practice Address - Street 1:5805 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2459
Practice Address - Country:US
Practice Address - Phone:218-624-5965
Practice Address - Fax:218-624-4628
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMN81561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN686817700Medicaid