Provider Demographics
NPI:1225313042
Name:BANKS, JAKE HENRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:HENRY
Last Name:BANKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 NOVATO BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-3048
Mailing Address - Country:US
Mailing Address - Phone:775-830-2252
Mailing Address - Fax:
Practice Address - Street 1:1730 NOVATO BLVD STE A
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3048
Practice Address - Country:US
Practice Address - Phone:775-830-2252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist