Provider Demographics
NPI:1922024934
Name:BANNISTER, JEROME A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:A
Last Name:BANNISTER
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 1:4370 PALM AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-1760
Mailing Address - Country:US
Mailing Address - Phone:619-428-8682
Mailing Address - Fax:619-428-1043
Practice Address - Street 1:4370 PALM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1760
Practice Address - Country:US
Practice Address - Phone:619-428-8682
Practice Address - Fax:619-428-1043
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA382531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice