Healthcare Provider Details

I. General information

NPI: 1336985076
Provider Name (Legal Business Name): AFFINITY DENTAL PEORIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 N UNIVERSITY ST STE C
PEORIA IL
61604-1348
US

IV. Provider business mailing address

3510 N UNIVERSITY ST STE C
PEORIA IL
61604-1348
US

V. Phone/Fax

Practice location:
  • Phone: 309-271-7777
  • Fax: 309-324-5777
Mailing address:
  • Phone: 309-271-7777
  • Fax: 309-324-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SRINIVAS DURSHANAPALLI
Title or Position: PRESIDENT
Credential:
Phone: 203-215-4687