MEDICARE: RACHEL SNOW INGRAM D.D.S.

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	019.028653	IL

General Provider Information

NPI Number	:	1528353893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHEL SNOW INGRAM D.D.S.

Provider Business Mailing Address
First Line	:	602 N RUSSELL ST
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61821-2635
Country	:	US
Telephone Number	:	217-417-1458
Fax Number	:

Provider Business Practice Location Address
First Line	:	2727 N OAKLAND AVE
Second Line	:	SUITE 102
City	:	DECATUR
State	:	IL
Zip	:	62526-1586
Country	:	US
Telephone Number	:	217-875-4222
Fax Number	:

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

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	12/10/2013

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