Healthcare Provider Details

I. General information

NPI: 1114363579
Provider Name (Legal Business Name): ANTHONY MITCHELL ELGER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N REGENCY DR
BLOOMINGTON IL
61701-3515
US

IV. Provider business mailing address

109 N REGENCY DR
BLOOMINGTON IL
61701-3515
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-2526
  • Fax: 309-663-4788
Mailing address:
  • Phone: 309-663-2526
  • Fax: 309-663-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number01902926
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number01902926
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: