=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699205344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BANKS DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8244 S ASHLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60620-4660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-651-8700
-----------------------------------------------------
Fax | 773-651-8711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8244 S ASHLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60620-4660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-651-8700
-----------------------------------------------------
Fax | 773-651-8711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST OWNER
-----------------------------------------------------
Name | DR. CHRISTOHER P. BANKS
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 773-651-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019026355
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------