Provider Demographics
NPI:1962526277
Name:COLUMBIA ORTHODONTICS
Entity type:Organization
Organization Name:COLUMBIA ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
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:618-281-3399
Mailing Address - Street 1:1060 ADMIRAL WEINEL BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1988
Mailing Address - Country:US
Mailing Address - Phone:618-281-3399
Mailing Address - Fax:618-281-3390
Practice Address - Street 1:1060 ADMIRAL WEINEL BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1988
Practice Address - Country:US
Practice Address - Phone:618-281-3399
Practice Address - Fax:618-281-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0158761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty