Provider Demographics
NPI:1417357518
Name:WADE MELVIN BANNER D.M.D., INC
Entity Type:Organization
Organization Name:WADE MELVIN BANNER D.M.D., INC
Other - Org Name:IN MOTION DENTISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:BANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-594-0374
Mailing Address - Street 1:2060 E ROUTE 66 STE 105
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4691
Mailing Address - Country:US
Mailing Address - Phone:626-594-0374
Mailing Address - Fax:626-594-0813
Practice Address - Street 1:2060 E ROUTE 66 STE 105
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4691
Practice Address - Country:US
Practice Address - Phone:626-594-0374
Practice Address - Fax:626-594-0813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty