Healthcare Provider Details

I. General information

NPI: 1720531759
Provider Name (Legal Business Name): DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 S MOUNT ZION RD
DECATUR IL
62521-9771
US

IV. Provider business mailing address

3040 S MOUNT ZION RD
DECATUR IL
62521-9771
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-4494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: HEATHER PRUEMER
Title or Position: CREDENTIALING TEAM LEAD
Credential:
Phone: 217-540-8434