MEDICARE: DR. PHILIP R BANGHART 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	019-021176	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982609087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP R BANGHART D.D.S.

Provider Business Mailing Address
First Line	:	102 PROFESSIONAL PLZ
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9252
Country	:	US
Telephone Number	:	217-345-7070
Fax Number	:	217-345-7077

Provider Business Practice Location Address
First Line	:	102 PROFESSIONAL PLZ
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9252
Country	:	US
Telephone Number	:	217-345-7070
Fax Number	:	217-345-7077

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

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	11/10/2008

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Directions to “ DR. PHILIP R BANGHART D.D.S.” Practice Location

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