Organization
MAPLE SHADE DENTAL CAMP STREET LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MIKE COLE (INSURANCE DIRECTOR)
(727) 726-1611
Entity
Organization
Contact information
Practice address
809 W CAMP ST, EAST PEORIA, IL 61611-7218
(309) 694-0606
Mailing address
809 W CAMP ST, EAST PEORIA, IL 61611-7218
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
IL
Other
Enumeration date
08/28/2012
Last updated
08/28/2012
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