Healthcare Provider Details

I. General information

NPI: 1023825114
Provider Name (Legal Business Name): DINNESHIA ANNETTA MOTEN DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS OSBORNE DENTAL CLINIC 3440 OHIO ST
GREAT LAKES IL
60088
US

IV. Provider business mailing address

4113 SKATE CT APT A
GREAT LAKES IL
60088-1134
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2100
  • Fax:
Mailing address:
  • Phone: 256-770-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10503
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: