Healthcare Provider Details

I. General information

NPI: 1629591854
Provider Name (Legal Business Name): PRAMOD TADAKAMALLA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
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 Number019031274
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031274
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: