Provider Demographics
NPI:1295231975
Name:BANKS, RAVEN (DMD)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3728 CRAIN HWY UNIT 105
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3728 CRAIN HWY UNIT 105
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4888
Practice Address - Country:US
Practice Address - Phone:240-448-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014165021223G0001X
390200000X
MD179561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty