Provider Demographics
NPI:1568485225
Name:BALLOON, CRAIG AMBROSE (DDS)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:AMBROSE
Last Name:BALLOON
Suffix:
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 1:2410 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-3613
Mailing Address - Country:US
Mailing Address - Phone:330-453-9980
Mailing Address - Fax:330-453-9981
Practice Address - Street 1:2410 CLEVELAND AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3613
Practice Address - Country:US
Practice Address - Phone:330-453-9980
Practice Address - Fax:330-453-9981
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH160311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice