MEDICARE: DR. JACOB CHRISTOPHER BALKOS BSC, DDS

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	1223P0221X	Pediatric Dentistry	ETN526	TX
2	1223P0221X	Pediatric Dentistry	34969	TX

General Provider Information

NPI Number	:	1285103291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB CHRISTOPHER BALKOS BSC, DDS

Provider Business Mailing Address
First Line	:	6756 POSS RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78238-2258
Country	:	US
Telephone Number	:	210-680-7841
Fax Number	:	210-680-3503

Provider Business Practice Location Address
First Line	:	6756 POSS RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78238-2258
Country	:	US
Telephone Number	:	201-680-7841
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2018
Last Update Date	:	08/19/2019

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