Provider Demographics
NPI:1487672531
Name:BALKCOM, JIMMY S (DMD,PC)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:S
Last Name:BALKCOM
Suffix:
Gender:M
Credentials:DMD,PC
Other - Prefix:DR
Other - First Name:J.S.
Other - Middle Name:
Other - Last Name:BALKCOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1442 ORLEANS CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1072
Mailing Address - Country:US
Mailing Address - Phone:770-979-9064
Mailing Address - Fax:770-979-5000
Practice Address - Street 1:2310 HENRY CLOWER BLVD STE C
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5776
Practice Address - Country:US
Practice Address - Phone:770-972-2000
Practice Address - Fax:770-979-5000
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA89741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice