Provider Demographics
NPI:1114930567
Name:BALCOS, CELINA MICHELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CELINA
Middle Name:MICHELLE
Last Name:BALCOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2339 LAKE HARBIN RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1905
Mailing Address - Country:US
Mailing Address - Phone:770-961-1222
Mailing Address - Fax:770-961-6121
Practice Address - Street 1:2339 LAKE HARBIN RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1905
Practice Address - Country:US
Practice Address - Phone:770-961-1222
Practice Address - Fax:770-961-6121
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0121001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1784060OtherUNITED CONCORDIA
GA100272OtherAVESIS
GA9181249OtherDORAL