Provider Demographics
NPI:1003161233
Name:BANTA, CRAIG ALLAN (MD)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ALLAN
Last Name:BANTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 CUMMING HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8614
Mailing Address - Country:US
Mailing Address - Phone:770-345-9600
Mailing Address - Fax:770-345-9611
Practice Address - Street 1:2050 CUMMING HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8614
Practice Address - Country:US
Practice Address - Phone:770-345-9600
Practice Address - Fax:770-345-9611
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48873174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist