Individual
CHARLES JACK BANTA II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
8220 WALNUT HILL LN STE 608, DALLAS, TX 75231-4424
(214) 987-3434
(214) 987-3799
Mailing address
8220 WALNUT HILL LN STE 608, DALLAS, TX 75231-4424
(214) 987-3434
(214) 987-3799
Taxonomy
Speciality
Code
Description
License number
State
207XS0117X
Orthopaedic Surgery of the Spine Physician
Primary
J0438
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
81W560
BLUE CROSS
TX
Enumeration date
08/13/2006
Last updated
07/08/2007
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