Healthcare Provider Details

I. General information

NPI: 1467438374
Provider Name (Legal Business Name): JEFFREY CHARLES BANKER DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 OLD COLLINSVILLE RD
SWANSEA IL
62226-2441
US

IV. Provider business mailing address

1837 RIVIERA LN
O FALLON IL
62269-6698
US

V. Phone/Fax

Practice location:
  • Phone: 618-236-0501
  • Fax:
Mailing address:
  • Phone: 618-628-6381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019020543
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: