Provider Demographics
NPI:1427116854
Name:MAPLE SHADE DENTAL GROUP
Entity type:Organization
Organization Name:MAPLE SHADE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:WILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-243-7702
Mailing Address - Street 1:11825 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525
Mailing Address - Country:US
Mailing Address - Phone:309-243-7702
Mailing Address - Fax:309-243-9559
Practice Address - Street 1:11825 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525
Practice Address - Country:US
Practice Address - Phone:309-243-7702
Practice Address - Fax:309-243-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty