Provider Demographics
NPI:1073026621
Name:BANNISTER, NATOSHA L
Entity Type:Individual
Prefix:
First Name:NATOSHA
Middle Name:L
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1127
Mailing Address - Country:US
Mailing Address - Phone:503-280-2877
Mailing Address - Fax:
Practice Address - Street 1:1314 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1127
Practice Address - Country:US
Practice Address - Phone:503-280-2877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant