Alexander Dmitry Banketov, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

8056 Issued in NE

Practice address

4920 S 30TH St Ste 103
Omaha, NE 68107-1656

Phone

(402) 734-4110

Fax

(402) 734-3990

NPI assigned

Jul 29, 2024

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in NE

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Ryan, James, Wiles, Patel & Olsen LLP

  dba Southeastern Dental Specialists

  • Dentist
  • Fayetteville, NC
  • NPI 1346473279
  NPD (past)
• Ryan, James, Wiles, Patel & Olsen LLP

  dba Village Family Dental

  • Dentist
  • Fayetteville, NC
  • NPI 1750495693
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1722211200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1736899200000",
    "number": "1124857164",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4920 S 30TH ST STE 103",
            "city": "OMAHA",
            "state": "NE",
            "postal_code": "681071656",
            "telephone_number": "402-734-4110",
            "fax_number": "402-734-3990"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4920 S 30TH ST STE 103",
            "city": "OMAHA",
            "state": "NE",
            "postal_code": "681071656",
            "telephone_number": "402-734-4110",
            "fax_number": "402-734-3990"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BANKETOV",
        "first_name": "ALEXANDER",
        "middle_name": "DMITRY",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2024-07-29",
        "last_updated": "2025-01-15",
        "certification_date": "2025-01-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NC",
            "license": "13921",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NE",
            "license": "8056",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Madyson Banitt
• Subash C Baniya, PHARMD
• Shauna Bank
• Ana Banker
• Diana Banker
• James Bankhead
• Mopelola Bankole, APRN
• Alexis Tatianna Banks, BCBA
• Cassaundra Deneen Banks, LPN
• Elizabeth Banks, MS, CCC-SLP

• Dentist in Omaha, NE
• Providers in Omaha, NE by specialty
• Dentist in Nebraska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 15, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.