Provider Demographics
NPI:1275606592
Name:JOHN B. DALE, DMD, MS, P.C.
Entity Type:Organization
Organization Name:JOHN B. DALE, DMD, MS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:309-691-9100
Mailing Address - Street 1:7314 N WILLOW LAKE CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8277
Mailing Address - Country:US
Mailing Address - Phone:309-691-9100
Mailing Address - Fax:309-691-6755
Practice Address - Street 1:7314 N WILLOW LAKE CT
Practice Address - Street 2:SUITE A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8277
Practice Address - Country:US
Practice Address - Phone:309-691-9100
Practice Address - Fax:309-691-6755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0020481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty