Healthcare Provider Details

I. General information

NPI: 1093642001
Provider Name (Legal Business Name): AFFINITY DENTAL PEORIA HEIGHTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 N PROSPECT RD STE S5
PEORIA HEIGHTS IL
61616-6578
US

IV. Provider business mailing address

4450 N PROSPECT RD STE S5
PEORIA HEIGHTS IL
61616-6578
US

V. Phone/Fax

Practice location:
  • Phone: 309-327-3333
  • Fax: 309-561-7333
Mailing address:
  • Phone: 309-327-3333
  • Fax: 309-561-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SRINIVAS DURSHANAPALLI
Title or Position: PRESIDENT
Credential: DDS
Phone: 888-244-8899