Provider Demographics
NPI:1912163098
Name:BANGLE, PHILLIP LEE
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LEE
Last Name:BANGLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 SUMMIT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3200
Mailing Address - Country:US
Mailing Address - Phone:262-542-1662
Mailing Address - Fax:
Practice Address - Street 1:1425 SUMMIT AVE STE 200
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3200
Practice Address - Country:US
Practice Address - Phone:262-542-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist