=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417357518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WADE MELVIN BANNER D.M.D., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2014
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2060 E ROUTE 66 STE 105
-----------------------------------------------------
City | GLENDORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91740-4691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-594-0374
-----------------------------------------------------
Fax | 626-594-0813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 929 W. FOOTHILL BLVD. SUITE A
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-594-0374
-----------------------------------------------------
Fax | 626-594-0813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WADE MELVIN BANNER
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 626-594-0374
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 63601
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------