Provider Demographics
NPI:1700158227
Name:DALE, JOHN B (,DMD, MS, PC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:DALE
Suffix:
Gender:M
Credentials:,DMD, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210020481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics