Provider Demographics
NPI:1528289527
Name:BALLA, ANDREA ELISABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:ELISABETH
Last Name:BALLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S MELBORN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-565-6080
Mailing Address - Fax:313-565-6080
Practice Address - Street 1:5760 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:98127
Practice Address - Country:US
Practice Address - Phone:313-277-2107
Practice Address - Fax:313-277-2108
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1958214590OtherBLUE CROSS BLUE SHIELD