=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417778481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDG BALCONES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2024
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6500 N MOPAC EXPRESSWAY BLDG 2 STE 2103
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-346-3427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9099 KATY FWY STE 140
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-465-1860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCE OFFICER
-----------------------------------------------------
Name | MS. THERESA NAVARRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-677-9983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------