Healthcare Provider Details

I. General information

NPI: 1982609087
Provider Name (Legal Business Name): PHILIP R BANGHART D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PROFESSIONAL PLZ
MATTOON IL
61938-9252
US

IV. Provider business mailing address

102 PROFESSIONAL PLZ
MATTOON IL
61938-9252
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-7070
  • Fax: 217-345-7077
Mailing address:
  • Phone: 217-345-7070
  • Fax: 217-345-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019-021176
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: