Provider Demographics
NPI:1134692858
Name:SHADY OAK DENTAL LLC - ROCHELLE FAMILY DENTAL
Entity Type:Organization
Organization Name:SHADY OAK DENTAL LLC - ROCHELLE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-275-2680
Mailing Address - Street 1:409 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1642
Practice Address - Country:US
Practice Address - Phone:815-561-6058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental