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General NPI Number Information
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NPI Number | 1134416795
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Entity Type | Organization
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Legal Business Name | MAPLE SHADE DENTAL (DUNLAP) LLC
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Dates
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Enumeration Date | 07/05/2011
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Last Update Date | 03/18/2024
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Provider Practice Location Address
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Address Line | 11825 STATE ROUTE 40 SUITE 200
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City | DUNLAP
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State | IL
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Zip | 61525-8842
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Country | US
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Telephone | 309-243-7702
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Fax | 309-243-9061
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Provider Business Mailing Address
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Address Line | 6240 LAKE OSPREY DR DEPT 56058
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City | LAKEWOOD RANCH
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State | FL
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Zip | 34240-8421
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | INSURANCE DIRECTOR
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Name | MIKE COLE
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Credential |
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Telephone | 727-726-1611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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