Provider Demographics
NPI:1366593097
Name:MICHAEL BANAWIS DDS PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MICHAEL BANAWIS DDS PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:BANAWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-357-9801
Mailing Address - Street 1:1745 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2551
Mailing Address - Country:US
Mailing Address - Phone:626-357-9801
Mailing Address - Fax:626-358-1706
Practice Address - Street 1:1745 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2551
Practice Address - Country:US
Practice Address - Phone:626-357-9801
Practice Address - Fax:626-358-1706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA492781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA523009OtherDENTICAL