Healthcare Provider Details

I. General information

NPI: 1437703113
Provider Name (Legal Business Name): SHADY OAK DENTAL LLC ORAL AND MAXILLOFACIAL SURGEONS OF NORTHWEST IL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 N WALNUT AVE
FORRESTON IL
61030-9330
US

IV. Provider business mailing address

208 N WALNUT AVE
FORRESTON IL
61030-9330
US

V. Phone/Fax

Practice location:
  • Phone: 815-938-2575
  • Fax:
Mailing address:
  • Phone: 815-938-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT C BARES
Title or Position: PRESIDENT
Credential: DDS
Phone: 815-938-2575