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General NPI Number Information
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NPI Number | 1528353893
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Entity Type | Individual
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Provider Name | RACHEL SNOW INGRAM D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 06/15/2011
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Last Update Date | 12/10/2013
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Provider Practice Location Address
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Address Line | 2727 N OAKLAND AVE SUITE 102
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City | DECATUR
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State | IL
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Zip | 62526-1586
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Country | US
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Telephone | 217-875-4222
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Fax |
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Provider Business Mailing Address
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Address Line | 602 N RUSSELL ST
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City | CHAMPAIGN
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State | IL
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Zip | 61821-2635
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Country | US
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Telephone | 217-417-1458
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.028653
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License Number State | IL
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