Provider Demographics
NPI:1023541695
Name:BANKS, CARLEY (ADT)
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:CARLEY
Other - Middle Name:
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ADT
Mailing Address - Street 1:1575 20TH ST NW
Mailing Address - Street 2:STE 102
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2930
Mailing Address - Country:US
Mailing Address - Phone:507-334-6433
Mailing Address - Fax:
Practice Address - Street 1:1575 20TH ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-334-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT17125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist