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General NPI Number Information
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NPI Number | 1417583592
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL DENTAL ALLIANCE OF GROVE DENTAL LLC
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Dates
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Enumeration Date | 03/20/2020
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Last Update Date | 04/29/2021
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Provider Practice Location Address
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Address Line | 160 E BOUGHTON RD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-2014
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Country | US
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Telephone | 630-759-8940
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 715279
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City | CINCINNATI
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State | OH
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Zip | 45271-5279
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | AMANDA KURTZ
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Credential |
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Telephone | 724-698-2058
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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