Provider Demographics
NPI:1497971097
Name:BANKS, MICHAEL DWAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DWAINE
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 1:606 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2519
Mailing Address - Country:US
Mailing Address - Phone:903-586-1551
Mailing Address - Fax:903-586-1552
Practice Address - Street 1:606 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2519
Practice Address - Country:US
Practice Address - Phone:903-586-1551
Practice Address - Fax:903-586-1552
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice