Provider Demographics
NPI:1417357518
Name:WADE MELVIN BANNER D.M.D., INC
Entity type:Organization
Organization Name:WADE MELVIN BANNER D.M.D., INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:BANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-594-0374
Mailing Address - Street 1:929 W. FOOTHILL BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3223
Mailing Address - Country:US
Mailing Address - Phone:626-594-0374
Mailing Address - Fax:626-594-0813
Practice Address - Street 1:2060 E ROUTE 66 STE 105
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4691
Practice Address - Country:US
Practice Address - Phone:626-594-0374
Practice Address - Fax:626-594-0813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63601122300000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental