Provider Demographics
NPI:1730585993
Name:BANKS, STACIE A (RDH, EP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:A
Last Name:BANKS
Suffix:
Gender:F
Credentials:RDH, EP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 ZINFANDEL LN
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3873
Mailing Address - Country:US
Mailing Address - Phone:541-914-9027
Mailing Address - Fax:
Practice Address - Street 1:1321 ZINFANDEL LN
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3873
Practice Address - Country:US
Practice Address - Phone:541-914-9027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2616124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist