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General NPI Number Information
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NPI Number | 1134692858
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Entity Type | Organization
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Legal Business Name | SHADY OAK DENTAL LLC - ROCHELLE FAMILY DENTAL
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Dates
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Enumeration Date | 01/04/2019
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Last Update Date | 01/04/2019
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Provider Practice Location Address
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Address Line | 409 LINCOLN HWY
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City | ROCHELLE
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State | IL
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Zip | 61068-1642
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Country | US
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Telephone | 815-561-6058
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Fax |
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Provider Business Mailing Address
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Address Line | 409 LINCOLN HWY
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City | ROCHELLE
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State | IL
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Zip | 61068-1642
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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 | DOCTOR
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Name | DR. SCOTT BARES
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Credential |
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Telephone | 815-275-2680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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