Provider Demographics
NPI:1982609087
Name:BANGHART, PHILIP R (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:R
Last Name:BANGHART
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9252
Mailing Address - Country:US
Mailing Address - Phone:217-345-7070
Mailing Address - Fax:217-345-7077
Practice Address - Street 1:102 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9252
Practice Address - Country:US
Practice Address - Phone:217-345-7070
Practice Address - Fax:217-345-7077
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0211761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-021176Medicaid
ILU57907Medicare UPIN
IL019-021176Medicaid