Provider Demographics
NPI:1053803494
Name:BALE, DILLON MATTHEW (DMD)
Entity type:Individual
Prefix:DR
First Name:DILLON
Middle Name:MATTHEW
Last Name:BALE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 DR MARTIN LUTHER KING ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-1108
Mailing Address - Country:US
Mailing Address - Phone:727-525-4499
Mailing Address - Fax:
Practice Address - Street 1:7801 DR MARTIN LUTHER KING ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-1108
Practice Address - Country:US
Practice Address - Phone:727-525-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN233681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty