Provider Demographics
NPI:1104668391
Name:LINCOLNWAY DENTAL LLC
Entity type:Organization
Organization Name:LINCOLNWAY 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:
Authorized Official - Last Name:BARES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-275-2680
Mailing Address - Street 1:1342 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6231
Mailing Address - Country:US
Mailing Address - Phone:815-275-2680
Mailing Address - Fax:
Practice Address - Street 1:2501 E LINCOLNWAY UNIT 3
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-3055
Practice Address - Country:US
Practice Address - Phone:815-275-2680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR SCOTT BARES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental