Provider Demographics
NPI:1215196290
Name:AFFILIATES IN ORAL & MAXILLOFACIAL SURGERY LTD
Entity Type:Organization
Organization Name:AFFILIATES IN ORAL & MAXILLOFACIAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:R
Authorized Official - Last Name:BANGHART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-351-7111
Mailing Address - Street 1:3112 VILLAGE OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7680
Mailing Address - Country:US
Mailing Address - Phone:217-351-7111
Mailing Address - Fax:217-351-7282
Practice Address - Street 1:3112 VILLAGE OFFICE PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7680
Practice Address - Country:US
Practice Address - Phone:217-351-7111
Practice Address - Fax:217-351-7282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190211761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty