Provider Demographics
NPI:1578138376
Name:BANOUB, PRESTON ALLEN MERCURIUS (DMD)
Entity Type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:ALLEN MERCURIUS
Last Name:BANOUB
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 1:6447 RIVERDALE LN
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2853
Mailing Address - Country:US
Mailing Address - Phone:262-271-2571
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST UNIT 611
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program