Provider Demographics
NPI:1134416795
Name:MAPLE SHADE DENTAL (DUNLAP) LLC
Entity type:Organization
Organization Name:MAPLE SHADE DENTAL (DUNLAP) LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-1611
Mailing Address - Street 1:6240 LAKE OSPREY DR DEPT 56058
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11825 STATE ROUTE 40
Practice Address - Street 2:SUITE 200
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-8842
Practice Address - Country:US
Practice Address - Phone:309-243-7702
Practice Address - Fax:309-243-9061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty