Provider Demographics
NPI:1437703113
Name:SHADY OAK DENTAL LLC ORAL AND MAXILLOFACIAL SURGEONS OF NORTHWEST IL
Entity type:Organization
Organization Name:SHADY OAK DENTAL LLC ORAL AND MAXILLOFACIAL SURGEONS OF NORTHWEST IL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:C
Authorized Official - Last Name:BARES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-938-2575
Mailing Address - Street 1:208 N WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:FORRESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61030-9330
Mailing Address - Country:US
Mailing Address - Phone:815-938-2575
Mailing Address - Fax:
Practice Address - Street 1:208 N WALNUT AVE
Practice Address - Street 2:
Practice Address - City:FORRESTON
Practice Address - State:IL
Practice Address - Zip Code:61030-9330
Practice Address - Country:US
Practice Address - Phone:815-938-2575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery