Provider Demographics
NPI:1750630646
Name:BANKS, KEVIN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
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 1:57 THOMAS JOHNSON DR STE A
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4670
Mailing Address - Country:US
Mailing Address - Phone:301-404-1665
Mailing Address - Fax:
Practice Address - Street 1:57 THOMAS JOHNSON DR STE A
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4670
Practice Address - Country:US
Practice Address - Phone:301-404-1665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15292122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist