Provider Demographics
NPI:1124857164
Name:BANKETOV, ALEXANDER DMITRY (DDS)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DMITRY
Last Name:BANKETOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 S 30TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1656
Mailing Address - Country:US
Mailing Address - Phone:402-734-4110
Mailing Address - Fax:402-734-3990
Practice Address - Street 1:4920 S 30TH ST STE 103
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1656
Practice Address - Country:US
Practice Address - Phone:402-734-4110
Practice Address - Fax:402-734-3990
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13921122300000X
NE8056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist