| Affiliates In Oral & Maxillofacial Surgery Ltd | |
|
3112 Village Office Pl Champaign IL 61822-7680 | |
| (217) 351-7111 | |
| (217) 351-7282 |
| Full Name | Affiliates In Oral & Maxillofacial Surgery Ltd |
|---|---|
| Speciality | Dentist |
| Location | 3112 Village Office Pl, Champaign, Illinois |
| Authorized Official Name and Position | Philip R. Banghart (PRESIDENT/ORAL SURGEON) |
| Authorized Official Contact | 2173517111 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Affiliates In Oral & Maxillofacial Surgery Ltd 3112 Village Office Pl Champaign IL 61822-7680 Ph: (217) 351-7111 | Affiliates In Oral & Maxillofacial Surgery Ltd 3112 Village Office Pl Champaign IL 61822-7680 Ph: (217) 351-7111 |
| NPI Number | 1215196290 |
|---|---|
| Provider Enumeration Date | 06/05/2008 |
| Last Update Date | 06/05/2008 |
| Medicare PECOS PAC ID | 0345309779 |
|---|---|
| Medicare Enrollment ID | O20081030000231 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215196290 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | 019021176 (Illinois) | Primary |
| Provider Name | Philip R Banghart |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1982609087 PECOS PAC ID: 5193884534 Enrollment ID: I20081030000324 |
| Provider Name | Theron C Waisath |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1144423963 PECOS PAC ID: 0446433759 Enrollment ID: I20110324000222 |
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