Provider Demographics
NPI:1528353893
Name:INGRAM, RACHEL SNOW (DDS)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:SNOW
Last Name:INGRAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2635
Mailing Address - Country:US
Mailing Address - Phone:217-417-1458
Mailing Address - Fax:
Practice Address - Street 1:2727 N OAKLAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1586
Practice Address - Country:US
Practice Address - Phone:217-875-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028653122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist