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General NPI Number Information
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NPI Number | 1356465629
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Entity Type | Organization
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Legal Business Name | WENTZVILLE ORTHODONTICS
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 08/04/2008
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Provider Practice Location Address
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Address Line | 1051 W PEARCE BLVD
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City | WENTZVILLE
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State | MO
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Zip | 63385-1019
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Country | US
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Telephone | 636-332-2350
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Fax |
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Provider Business Mailing Address
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Address Line | 1051 W PEARCE BLVD
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City | WENTZVILLE
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State | MO
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Zip | 63385-1019
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Country | US
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Telephone | 636-332-2350
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Fax |
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. BRENT DEE BANKHEAD
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Credential | DDS, MS
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Telephone | 636-332-2350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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