Provider Demographics
NPI:1710099387
Name:BANISTER, ROBERT BRADLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRADLEY
Last Name:BANISTER
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 1:4 MEDICAL LN
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4913
Mailing Address - Country:US
Mailing Address - Phone:501-329-5205
Mailing Address - Fax:501-329-6038
Practice Address - Street 1:4 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4913
Practice Address - Country:US
Practice Address - Phone:501-329-5205
Practice Address - Fax:501-329-6038
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice