MEDICARE: STATELINE DENTISTRY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1346126182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATELINE DENTISTRY PC

Provider Business Mailing Address
First Line	:	3700 IL ROUTE 173
Second Line	:
City	:	RICHMOND
State	:	IL
Zip	:	60071-9614
Country	:	US
Telephone Number	:	815-701-6411
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 IL ROUTE 173
Second Line	:
City	:	RICHMOND
State	:	IL
Zip	:	60071-9614
Country	:	US
Telephone Number	:	815-701-6411
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	AMANDA ROBERTS
Credential	:
Telephone Number	:	815-385-4140

Provider Enumeration Date	:	08/15/2025
Last Update Date	:	08/15/2025

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Directions to “STATELINE DENTISTRY PC ” Practice Location

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