Provider Demographics
NPI:1962177733
Name:BALLAN D TUCK DDS INC
Entity type:Organization
Organization Name:BALLAN D TUCK DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING/MANAGING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BALLAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-251-1962
Mailing Address - Street 1:1375 GRAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1076
Mailing Address - Country:US
Mailing Address - Phone:510-251-1962
Mailing Address - Fax:510-251-8333
Practice Address - Street 1:1375 GRAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:CA
Practice Address - Zip Code:94610-1076
Practice Address - Country:US
Practice Address - Phone:510-251-1962
Practice Address - Fax:510-251-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-12
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty