NPIMap

Organization Active NPI

Shady Oak Dental LLC Oral and Maxillofacial Surgeons of Northwest Il

  • Oral and Maxillofacial Surgery Clinic/Center
  • Forreston, IL
National Provider Identifier
1437703113
Registry record updated Jul 30, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery Clinic/CenterTaxonomy code 261QS0112X
Legal business name
SHADY OAK DENTAL LLC ORAL AND MAXILLOFACIAL SURGEONS OF NORTHWEST IL
Practice address
208 N Walnut Ave
Forreston, IL 61030-9330
Phone
(815) 938-2575
NPI assigned
Jul 30, 2019
Last updated
Jul 30, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 30, 2019

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

Authorized official

Name
Dr. Scott C Bares, DDS
Title
President
Phone
(815) 938-2575

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery Clinic/Center 261QS0112X NU Primary

Addresses

Primary practice location

208 N Walnut Ave
Forreston, IL 61030-9330

Mailing address

208 N Walnut Ave
Forreston, IL 61030-9330
Phone (815) 938-2575

National Provider Directory

National Provider Directory

Locations

208 N Walnut Ave
Forreston, IL 61030
Phone (815) 938-2575

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1564444800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1564444800000",
    "number": "1437703113",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "208 N WALNUT AVE",
            "city": "FORRESTON",
            "state": "IL",
            "postal_code": "610309330",
            "telephone_number": "815-938-2575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "208 N WALNUT AVE",
            "city": "FORRESTON",
            "state": "IL",
            "postal_code": "610309330",
            "telephone_number": "815-938-2575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADY OAK DENTAL LLC ORAL AND MAXILLOFACIAL SURGEONS OF NORTHWEST IL",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-07-30",
        "last_updated": "2019-07-30",
        "status": "A",
        "authorized_official_last_name": "BARES",
        "authorized_official_first_name": "SCOTT",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "815-938-2575",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "261QS0112X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Oral and Maxillofacial Surgery",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Forreston, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 30, 2019; 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.