Provider Demographics
NPI:1235133661
Name:BANKSTON, STEPHEN A (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:BANKSTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JOHNSON FERRY RD
Mailing Address - Street 2:BLDG H
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-5518
Mailing Address - Country:US
Mailing Address - Phone:770-977-0364
Mailing Address - Fax:678-819-6531
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:BLDG H
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5518
Practice Address - Country:US
Practice Address - Phone:770-977-0364
Practice Address - Fax:678-819-6531
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN00124181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU81007Medicare UPIN
GA19NCBZKMedicare ID - Type Unspecified