# FRED L BALLOU, DMD, PSC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619972205
- **Authorized official:** DR. FRED L BALLOU JR. DMD (PRESIDENT/OWNER)
- **Authorized official phone:** (859) 623-3818

## Contact information

- **Practice address:** 311 RADIO PARK DR, STE B, RICHMOND, KY 40475-2399
- **Practice address phone:** (859) 623-3818
- **Practice address fax:** (859) 624-1061
- **Mailing address:** 311 RADIO PARK DR, STE B, RICHMOND, KY 40475-2399
- **Mailing address phone:** (859) 623-3818
- **Mailing address fax:** (859) 624-1061

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 3905 | KY | Yes |

## Other

- **Enumeration date:** 06/20/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 532067 | UNITED CONCORDIA | KY |