Healthcare Provider Details

I. General information

NPI: 1568106003
Provider Name (Legal Business Name): FREDERICK BANKS JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 S VIENNA ST
RUSTON LA
71270-5834
US

IV. Provider business mailing address

PO BOX 1288
WINNFIELD LA
71483-1288
US

V. Phone/Fax

Practice location:
  • Phone: 318-224-7190
  • Fax:
Mailing address:
  • Phone: 318-628-2710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7505
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: