Provider Demographics
NPI:1952729279
Name:ORTHODONTIC ASSOCIATES OF COLUMBIA AND WATERLOO
Entity Type:Organization
Organization Name:ORTHODONTIC ASSOCIATES OF COLUMBIA AND WATERLOO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:BANKHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:618-281-7979
Mailing Address - Street 1:224 BRADFORD LN STE B
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-3369
Mailing Address - Country:US
Mailing Address - Phone:618-281-7979
Mailing Address - Fax:
Practice Address - Street 1:224 BRADFORD LANE SUITE B
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298
Practice Address - Country:US
Practice Address - Phone:618-939-7070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190252901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty