Organization
MAPLE SHADE DENTAL BLOOMINGTON LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MIKE COLE (VP INSURANCE PLAN MANAGEMENT)
(727) 726-1611
Entity
Organization
Contact information
Practice address
107 S PROSPECT RD, BLOOMINGTON, IL 61704-4403
(309) 663-0433
(309) 662-1372
Mailing address
107 S PROSPECT RD, BLOOMINGTON, IL 61704-4403
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
Other
Enumeration date
10/26/2012
Last updated
04/23/2015
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