Provider Demographics
NPI:1396351425
Name:SHADY OAK DENTAL LLC - BURLINGTON DENTAL
Entity type:Organization
Organization Name:SHADY OAK DENTAL LLC - BURLINGTON DENTAL
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:815-938-2575
Mailing Address - Street 1:255 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60109-1116
Mailing Address - Country:US
Mailing Address - Phone:847-683-9812
Mailing Address - Fax:
Practice Address - Street 1:255 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IL
Practice Address - Zip Code:60109-1116
Practice Address - Country:US
Practice Address - Phone:847-683-9812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHADY OAK DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty