Provider Demographics
NPI:1417583592
Name:PROFESSIONAL DENTAL ALLIANCE OF GROVE DENTAL LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF GROVE DENTAL LLC
Other - Org Name:GROVE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-698-2058
Mailing Address - Street 1:PO BOX 715279
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-5279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 E BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2014
Practice Address - Country:US
Practice Address - Phone:630-759-8940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-20
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental