MEDICARE: BANKHEAD DDS WARRENTON ORTHODONTICS PC

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	302R00000X	Health Maintenance Organization	015876	MO

General Provider Information

NPI Number	:	1528205267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANKHEAD DDS WARRENTON ORTHODONTICS PC

Provider Business Mailing Address
First Line	:	511 ASHLAND AVE
Second Line	:
City	:	WARRENTON
State	:	MO
Zip	:	63383-1065
Country	:	US
Telephone Number	:	636-456-3770
Fax Number	:	636-456-3779

Provider Business Practice Location Address
First Line	:	511 ASHLAND AVE
Second Line	:
City	:	WARRENTON
State	:	MO
Zip	:	63383-1065
Country	:	US
Telephone Number	:	636-456-3770
Fax Number	:	636-456-3779

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRENT DEE BANKHEAD
Credential	:	DDS, MS
Telephone Number	:	636-978-8848

Provider Enumeration Date	:	01/16/2009
Last Update Date	:	01/16/2009

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