Healthcare Provider Details

I. General information

NPI: 1609706043
Provider Name (Legal Business Name): ALYSSA BERRY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11041 W 179TH ST
ORLAND PARK IL
60467-9452
US

IV. Provider business mailing address

11041 W 179TH ST
ORLAND PARK IL
60467-9452
US

V. Phone/Fax

Practice location:
  • Phone: 708-627-2202
  • Fax:
Mailing address:
  • Phone: 708-627-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037277
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: