Provider Demographics
NPI:1013780394
Name:BANKS, LACI C
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:C
Last Name:BANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MO
Mailing Address - Zip Code:65622-4120
Mailing Address - Country:US
Mailing Address - Phone:417-733-5605
Mailing Address - Fax:
Practice Address - Street 1:1300 N OAKLAND AVE STE B
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3008
Practice Address - Country:US
Practice Address - Phone:417-326-6061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023021409124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist