Provider Demographics
NPI:1629780267
Name:ILLINOIS ENDODONTICS, LLC
Entity Type:Organization
Organization Name:ILLINOIS ENDODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATH
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-377-1499
Mailing Address - Street 1:1508 RIVER BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-3677
Mailing Address - Country:US
Mailing Address - Phone:217-377-1499
Mailing Address - Fax:
Practice Address - Street 1:2916 CROSSING CT STE C
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-5900
Practice Address - Country:US
Practice Address - Phone:217-352-5809
Practice Address - Fax:217-352-5812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental