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General NPI Number Information
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NPI Number | 1952729279
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Entity Type | Organization
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Legal Business Name | ORTHODONTIC ASSOCIATES OF COLUMBIA AND WATERLOO
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Dates
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Enumeration Date | 04/03/2014
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 224 BRADFORD LANE SUITE B
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City | WATERLOO
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State | IL
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Zip | 62298
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Country | US
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Telephone | 618-939-7070
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Fax |
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Provider Business Mailing Address
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Address Line | 224 BRADFORD LN STE B
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City | WATERLOO
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State | IL
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Zip | 62298-3369
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Country | US
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Telephone | 618-281-7979
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Fax |
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Authorized Official
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Title or Position | DR.
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Name | DR. BRENT DEE BANKHEAD
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Credential | DDS, MS
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Telephone | 618-281-7979
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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 | 019025290
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License Number State | IL
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