MEDICARE: DR. BRUCE GAIL SAMMONS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1194866699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE GAIL SAMMONS

Provider Business Mailing Address
First Line	:	3003 VILLAGE OFFICE PLACE
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-7674
Country	:	US
Telephone Number	:	217-359-4246
Fax Number	:

Provider Business Practice Location Address
First Line	:	3003 VILLAGE OFFICE PLACE
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-7674
Country	:	US
Telephone Number	:	217-359-4246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	07/08/2007

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Directions to “ DR. BRUCE GAIL SAMMONS ” Practice Location

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