Provider Demographics
NPI:1386093946
Name:BANGURA, CHANNELLE (RDH)
Entity type:Individual
Prefix:MRS
First Name:CHANNELLE
Middle Name:
Last Name:BANGURA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 CORTANA CT
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-1185
Mailing Address - Country:US
Mailing Address - Phone:410-279-4113
Mailing Address - Fax:
Practice Address - Street 1:8472 SIMMOND ST
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5700
Practice Address - Country:US
Practice Address - Phone:410-279-4113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-05
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17321124Q00000X
MD7740124Q00000X
KY4121124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist