Provider Demographics
NPI:1205188307
Name:BANIAS, AGNES BAUTISTA (RDH)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:BAUTISTA
Last Name:BANIAS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 ADMIRAL TAUSSIG BLVD BR HEALTH CLINIC
Mailing Address - Street 2:NAVAL MEDICAL CENTER PORTSMOUTH
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23511
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:1647 ADMIRAL TAUSSIG BLVD BR HEALTH CLINIC
Practice Address - Street 2:NAVAL MEDICAL CENTER PORTSMOUTH
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511
Practice Address - Country:US
Practice Address - Phone:757-953-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8471124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist