Maple Shade Dental (East Peoria) LLC

Primary specialty

DentistTaxonomy code 122300000X

Legal business name

MAPLE SHADE DENTAL (EAST PEORIA) LLC

Practice address

1001 Illini Dr
East Peoria, IL 61611-1883

Phone

(309) 694-2620

NPI assigned

May 10, 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

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Michael Connolly

  • Dentist
  • East Peoria, IL
  • NPI 1487921490
  NPD (past)
• Brockton Willey

  • Dentist
  • East Grand Rapids, MI
  • NPI 1598141087
  NPD (past)

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

{
    "created_epoch": "1304985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1784592000000",
    "number": "1245522267",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6240 LAKE OSPREY DR DEPT 56057",
            "city": "LAKEWOOD RANCH",
            "state": "FL",
            "postal_code": "342408421"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1001 ILLINI DR",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616111883",
            "telephone_number": "309-694-2620"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAPLE SHADE DENTAL (EAST PEORIA) LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-10",
        "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": []
}

• Barbara Lopez, APRN, CNP
• Alexis Marie Ludolph
• Viktor Maister, DMD
• Sarah E Makuta, LCSW
• Joanna Rae Malmquist
• Maple Shade Dental Camp Street LLC
• Mark E Brewer O D P C
• Tara Lynn Martin, APRN
• Vincent Capatan Martin, DPT
• Taylor Maxfield

• Dentist in East Peoria, IL
• Providers in East Peoria, 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.