Provider Demographics
NPI:1407835382
Name:BANTA, THOMAS M (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:BANTA
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 1:2786 S BUTTERNUT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-8740
Mailing Address - Country:US
Mailing Address - Phone:260-726-7822
Mailing Address - Fax:260-726-3513
Practice Address - Street 1:1413 W VOTAW ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-9501
Practice Address - Country:US
Practice Address - Phone:260-726-7822
Practice Address - Fax:260-726-3513
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice