Healthcare Provider Details

I. General information

NPI: 1801583570
Provider Name (Legal Business Name): PREMIER DENTAL GROUP PERSONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S WEST ST
WHEATON IL
60187-5021
US

IV. Provider business mailing address

183 N ADDISON AVE APT 216
ELMHURST IL
60126-3195
US

V. Phone/Fax

Practice location:
  • Phone: 630-665-0650
  • Fax: 708-484-0843
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY AMODIO BRUCCI
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 708-308-9929