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General NPI Number Information
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NPI Number | 1013780394
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Entity Type | Individual
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Provider Name | LACI C BANKS
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Gender | Female
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Dates
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Enumeration Date | 10/30/2023
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Last Update Date | 10/30/2023
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Provider Practice Location Address
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Address Line | 1300 N OAKLAND AVE STE B
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City | BOLIVAR
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State | MO
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Zip | 65613-3008
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Country | US
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Telephone | 417-326-6061
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Fax |
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Provider Business Mailing Address
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Address Line | 372 SPRINGFIELD RD
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City | BUFFALO
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State | MO
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Zip | 65622-4120
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Country | US
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Telephone | 417-733-5605
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 2023021409
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License Number State | MO
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