Provider Demographics
NPI:1124090212
Name:BANKS, KATHY A (DMD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:A
Last Name:BANKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 LAUREL BLVD
Mailing Address - Street 2:
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-2720
Mailing Address - Country:US
Mailing Address - Phone:609-488-2325
Mailing Address - Fax:609-488-2342
Practice Address - Street 1:249 S MAIN ST
Practice Address - Street 2:UNIT 4
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005-2301
Practice Address - Country:US
Practice Address - Phone:609-488-2325
Practice Address - Fax:609-488-2342
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ177921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU73971Medicare UPIN
NJ023967Medicare ID - Type Unspecified