=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669182333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL CORPORATION OF WADE MELVIN BANNER DMD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2022
-----------------------------------------------------
Last Update Date | 12/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 FOOTHILL BLVD STE B
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-973-0099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 929 FOOTHILL BLVD STE B
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WADE BANNER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 909-973-0099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------