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General NPI Number Information
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NPI Number | 1275606592
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Entity Type | Organization
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Legal Business Name | JOHN B. DALE, DMD, MS, P.C.
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 01/30/2012
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Provider Practice Location Address
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Address Line | 7314 N WILLOW LAKE CT SUITE A
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City | PEORIA
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State | IL
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Zip | 61614-8277
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Country | US
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Telephone | 309-691-9100
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Fax | 309-691-6755
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Provider Business Mailing Address
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Address Line | 7314 N WILLOW LAKE CT SUITE A
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City | PEORIA
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State | IL
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Zip | 61614-8277
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Country | US
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Telephone | 309-691-9100
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Fax | 309-691-6755
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. JOHN BRUCE DALE
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Credential | D.M.D., M.S.
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Telephone | 309-691-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 021.002048
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License Number State | IL
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