=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588519904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLOVE DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2026
-----------------------------------------------------
Last Update Date | 03/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4207 N PROSPECT RD
-----------------------------------------------------
City | PEORIA HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61616-7754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-323-8884
-----------------------------------------------------
Fax | 309-324-3336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4207 N PROSPECT RD
-----------------------------------------------------
City | PEORIA HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61616-7754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-323-8884
-----------------------------------------------------
Fax | 309-324-3336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. SANDEEP THOTA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 314-651-6550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------