# AFFILIATES IN ORAL & MAXILLOFACIAL SURGERY LTD

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215196290
- **Authorized official:** DR. PHILIP R. BANGHART DDS (PRESIDENT/ORAL SURGEON)
- **Authorized official phone:** (217) 351-7111

## Contact information

- **Practice address:** 3112 VILLAGE OFFICE PL, CHAMPAIGN, IL 61822-7680
- **Practice address phone:** (217) 351-7111
- **Practice address fax:** (217) 351-7282
- **Mailing address:** 3112 VILLAGE OFFICE PL, CHAMPAIGN, IL 61822-7680
- **Mailing address phone:** (217) 351-7111
- **Mailing address fax:** (217) 351-7282

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 019021176 | IL | Yes |

## Other

- **Enumeration date:** 06/05/2008
- **Last updated:** 06/05/2008