Organization
FREEPORT DENTAL
Active
Parent organization
SHADYOAK DENTAL
Organization subpart
Yes
Provider details
NPI number
Legal business name
SHADYOAK DENTAL
Authorized official
SCOTT BARES (OWNER)
(815) 656-4060
Entity
Organization
Contact information
Practice address
1450 S WEST AVE, FREEPORT, IL 61032-6351
(815) 656-4060
(815) 656-2324
Mailing address
1450 S WEST AVE, FREEPORT, IL 61032-6351
(815) 656-4060
(815) 656-2324
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019027024
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1164580734
GENERAL DENISTRY
—
Enumeration date
10/05/2015
Last updated
10/05/2015
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