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General NPI Number Information
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NPI Number | 1215196290
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Entity Type | Organization
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Legal Business Name | AFFILIATES IN ORAL & MAXILLOFACIAL SURGERY LTD
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Dates
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Enumeration Date | 06/05/2008
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Last Update Date | 06/05/2008
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Provider Practice Location Address
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Address Line | 3112 VILLAGE OFFICE PL
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City | CHAMPAIGN
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State | IL
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Zip | 61822-7680
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Country | US
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Telephone | 217-351-7111
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Fax | 217-351-7282
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Provider Business Mailing Address
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Address Line | 3112 VILLAGE OFFICE PL
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City | CHAMPAIGN
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State | IL
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Zip | 61822-7680
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Country | US
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Telephone | 217-351-7111
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Fax | 217-351-7282
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Authorized Official
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Title or Position | PRESIDENT/ORAL SURGEON
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Name | DR. PHILIP R. BANGHART
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Credential | DDS
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Telephone | 217-351-7111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 019021176
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License Number State | IL
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