Basic Information
| Provider Information | |||||||||
| NPI: | 1891123691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLA | ||||||||
| FirstName: | USHA | ||||||||
| MiddleName: | RANI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 1002221E | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 6725 ANNAPOLIS RD | ||||||||
| Address2: | |||||||||
| City: | LANDOVER HILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207841904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017734746 | ||||||||
| FaxNumber: | 3017734941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2013 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN1001619 | DC | N | Dental Providers | Dentist | 122300000X | 15914 | MD | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 079748100 | 05 | DC | MEDICAID | 029566300 | 05 | MD | MEDICAID |