Healthcare Provider Details

I. General information

NPI: 1750766358
Provider Name (Legal Business Name): TANEENOP ARAMPHONGPHAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
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:
Mailing address:
  • Phone: 973-847-4533
  • Fax: 309-663-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019030316
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: