Maple Shade Dental (Dunlap) LLC

Primary specialty

DentistTaxonomy code 122300000X

Legal business name

MAPLE SHADE DENTAL (DUNLAP) LLC

Practice address

11825 State Route 40
Suite 200
Dunlap, IL 61525-8842

Phone

(309) 243-7702

Fax

(309) 243-9061

NPI assigned

Jul 5, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Victoria J Johnson

Title

Cro

Phone

(941) 444-0558

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1309824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1784592000000",
    "number": "1134416795",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6240 LAKE OSPREY DR DEPT 56058",
            "city": "LAKEWOOD RANCH",
            "state": "FL",
            "postal_code": "342408421"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11825 STATE ROUTE 40",
            "address_2": "SUITE 200",
            "city": "DUNLAP",
            "state": "IL",
            "postal_code": "615258842",
            "telephone_number": "309-243-7702",
            "fax_number": "309-243-9061"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAPLE SHADE DENTAL (DUNLAP) LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-07-05",
        "last_updated": "2026-07-21",
        "certification_date": "2026-07-21",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "VICTORIA",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CRO",
        "authorized_official_telephone_number": "941-444-0558"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kids Thrive Therapy, LLC
• Amy E Kordonowy
• Michelle Lynn Lizer
• Angela Lollock, RD, IBCLC
• Denise M. Mammolito, M.D.
• Maple Shade Dental Group
• Mapleshade Vision Center Inc.
• Kami Maurer, FNP
• Hilary A McEvoy, M.A.
• Nizar N Merheb

• Dentist in Dunlap, IL
• Providers in Dunlap, IL by specialty
• Dentist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.