Healthcare Provider Details

I. General information

NPI: 1245428234
Provider Name (Legal Business Name): PRAIRIE AVENUE DENTAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12016 PRAIRIE AVE POST OFFICE BOX 75
HEBRON IL
60034-8892
US

IV. Provider business mailing address

12016 PRAIRIE AVE POST OFFICE BOX 75
HEBRON IL
60034-8892
US

V. Phone/Fax

Practice location:
  • Phone: 815-648-4095
  • Fax: 815-648-2881
Mailing address:
  • Phone: 815-648-4095
  • Fax: 815-648-2881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RENEE E. DIETZ
Title or Position: OWNER
Credential: D.M.D.
Phone: 815-648-4095