Provider Demographics
NPI:1831329812
Name:BANICH, JEFFREY S
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:BANICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 ROCKY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-9755
Mailing Address - Country:US
Mailing Address - Phone:509-684-3195
Mailing Address - Fax:
Practice Address - Street 1:775 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2514
Practice Address - Country:US
Practice Address - Phone:509-684-4586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600971611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice