MEDICARE: CLOVE DENTAL PLLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1588519904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLOVE DENTAL PLLC

Provider Business Mailing Address
First Line	:	4207 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7754
Country	:	US
Telephone Number	:	309-323-8884
Fax Number	:	309-324-3336

Provider Business Practice Location Address
First Line	:	4207 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7754
Country	:	US
Telephone Number	:	309-323-8884
Fax Number	:	309-324-3336

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. SANDEEP THOTA
Credential	:	DMD
Telephone Number	:	314-651-6550

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “CLOVE DENTAL PLLC ” Practice Location

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