MEDICARE: BALCONES FAMILY DENTAL GPS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1164158168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALCONES FAMILY DENTAL GPS PLLC

Provider Business Mailing Address
First Line	:	100 E HUNTINGTON AVE STE E
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72401-2900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9000 ANDERSON MILL RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78729-4501
Country	:	US
Telephone Number	:	512-920-6105
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. WILLIAM LITTLE
Credential	:	DDS
Telephone Number	:	870-243-4406

Provider Enumeration Date	:	08/01/2022
Last Update Date	:	08/01/2022

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