Healthcare Provider Details

I. General information

NPI: 1184467433
Provider Name (Legal Business Name): BANKHEAD DDS ORTHODONTICS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 STATE HIGHWAY N
LAKE ST. LOUIS MO
63367
US

IV. Provider business mailing address

3006 HWY K
O'FALLON MO
63368
US

V. Phone/Fax

Practice location:
  • Phone: 636-226-1050
  • Fax: 636-898-2001
Mailing address:
  • Phone: 636-978-8848
  • Fax: 636-294-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DARREN MCKAY RODABORUGH
Title or Position: OWNER
Credential: DDS
Phone: 636-978-8848