Maple Shade Dental Bloomington LLC

NPI #1366795437 in Bloomington, Illinois

Provider Information

NPI Number: 1366795437
Entity Type: Organization
Organization Name: Maple Shade Dental Bloomington LLC
Primary Specialty: Dentist
Enumeration Date: Oct 26, 2012
Last Updated: Apr 23, 2015

Practice Location

Address: 107 S PROSPECT RD
City: Bloomington
State: Illinois
ZIP Code: 61704-4403
Phone: (309) 663-0433

Authorized Official

Name: MIKE COLE
Title: VP INSURANCE PLAN MANAGEMENT
Phone: (727) 726-1611

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist	122300000X	Primary

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