Provider Demographics
NPI:1689785271
Name:BANAWIS, MICHAEL BABON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BABON
Last Name:BANAWIS
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 1:1745 HUNTINGTON DR.
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010
Mailing Address - Country:US
Mailing Address - Phone:626-357-9801
Mailing Address - Fax:626-358-1706
Practice Address - Street 1:1745 HUNTINGTON DR.
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010
Practice Address - Country:US
Practice Address - Phone:626-357-9801
Practice Address - Fax:626-358-1706
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA523009OtherDENTICAL