Provider Demographics
NPI:1891165643
Name:FREEPORT DENTAL
Entity Type:Organization
Organization Name:FREEPORT DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-656-4060
Mailing Address - Street 1:1450 S WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6351
Mailing Address - Country:US
Mailing Address - Phone:815-656-4060
Mailing Address - Fax:815-656-2324
Practice Address - Street 1:1450 S WEST AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6351
Practice Address - Country:US
Practice Address - Phone:815-656-4060
Practice Address - Fax:815-656-2324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHADYOAK DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190270241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164580734OtherGENERAL DENISTRY