Provider Demographics
NPI:1558145227
Name:PROFESSIONAL DENTAL ALLIANCE OF ILLINOIS SPECIALTY, PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF ILLINOIS SPECIALTY, PLLC
Other - Org Name:ASSOCIATED DENTAL SPECIALISTS OF LONG GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-901-1964
Mailing Address - Street 1:125 ENTERPRISE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15275-1223
Mailing Address - Country:US
Mailing Address - Phone:249-011-9647
Mailing Address - Fax:
Practice Address - Street 1:4160 IL ROUTE 83 STE 308
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-8034
Practice Address - Country:US
Practice Address - Phone:847-634-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-23
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty