Provider Demographics
NPI:1245428234
Name:PRAIRIE AVENUE DENTAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PRAIRIE AVENUE DENTAL ASSOCIATES, INC.
Other - Org Name:RENEE SCHULTZ DIETZ
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-648-4095
Mailing Address - Street 1:12016 PRAIRIE AVE
Mailing Address - Street 2:POST OFFICE BOX 75
Mailing Address - City:HEBRON
Mailing Address - State:IL
Mailing Address - Zip Code:60034-8892
Mailing Address - Country:US
Mailing Address - Phone:815-648-4095
Mailing Address - Fax:815-648-2881
Practice Address - Street 1:12016 PRAIRIE AVE
Practice Address - Street 2:POST OFFICE BOX 75
Practice Address - City:HEBRON
Practice Address - State:IL
Practice Address - Zip Code:60034-8892
Practice Address - Country:US
Practice Address - Phone:815-648-4095
Practice Address - Fax:815-648-2881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENEE E. SCHULTZ DIETZ
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty