Provider Demographics
NPI:1992202139
Name:PEORIA DENTAL LLC
Entity Type:Organization
Organization Name:PEORIA DENTAL LLC
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:309-981-5995
Mailing Address - Street 1:7417 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2019
Mailing Address - Country:US
Mailing Address - Phone:309-981-5995
Mailing Address - Fax:309-981-5981
Practice Address - Street 1:7417 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2019
Practice Address - Country:US
Practice Address - Phone:309-981-5995
Practice Address - Fax:309-981-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental