Maple Shade Dental Bloomington LLC

Primary specialty

DentistTaxonomy code 122300000X

Legal business name

MAPLE SHADE DENTAL BLOOMINGTON LLC

Practice address

107 S Prospect Rd
Bloomington, IL 61704-4403

Phone

(309) 663-0433

Fax

(309) 662-1372

NPI assigned

Oct 26, 2012

Organization subpart

No

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

Authorized official

Name

Victoria Johnson

Title

Cro

Phone

(941) 444-0558

Specialties & licenses 1

Addresses

Practitioners 2

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

• Clint Boyle, DMD

  • Dentist
  • Bloomington, IL
  • NPI 1851670152
  NPD (past)
• Christopher Probst, DMD

  • General Practice Dentistry
  • Frisco, TX
  • NPI 1043704075
  NPD (past)

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

{
    "created_epoch": "1351209600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1784678400000",
    "number": "1366795437",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "107 S PROSPECT RD",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617044403"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "107 S PROSPECT RD",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617044403",
            "telephone_number": "309-663-0433",
            "fax_number": "309-662-1372"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAPLE SHADE DENTAL BLOOMINGTON LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-26",
        "last_updated": "2026-07-22",
        "certification_date": "2026-07-22",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "VICTORIA",
        "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": []
}

• Harirajan Mani, MD
• Lukas Dominic Manieri, ATC, OTC
• Trisha Dyan Mann, PHD
• Courtney Manning, DPT
• Kristin Elizabeth Manzi, LCSW
• Gwenn None Marie, BCPP, BCTMB, LMT
• Charlotte M Markley, LCSW
• Jacob Daniel Marlow, H.I.D.
• Rebecca Marquart, LPC
• Debra L Marquis, PT

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

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 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.