Basic Information
| Provider Information | |||||||||
| NPI: | 1427116854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAPLE SHADE DENTAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11825 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | DUNLAP | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092437702 | ||||||||
| FaxNumber: | 3092439559 | ||||||||
| Practice Location | |||||||||
| Address1: | 11825 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | DUNLAP | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092437702 | ||||||||
| FaxNumber: | 3092439559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILLEY | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | EARL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3092437702 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223P0300X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223S0112X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.