Provider Demographics
NPI:1740812494
Name:BANKHEAD ALTON ORTHODONTICS PC
Entity type:Organization
Organization Name:BANKHEAD ALTON ORTHODONTICS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:REITMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-734-7876
Mailing Address - Street 1:3006 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8675
Mailing Address - Country:US
Mailing Address - Phone:636-734-7876
Mailing Address - Fax:636-898-2001
Practice Address - Street 1:2828 HOMER ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4855
Practice Address - Country:US
Practice Address - Phone:618-465-7423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANKHEAD ORTHODONTICS DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-11
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty