Provider Demographics
NPI:1265926729
Name:VOGUE DENTAL PEORIA LLC
Entity type:Organization
Organization Name:VOGUE DENTAL PEORIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:DURSHANAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-215-4687
Mailing Address - Street 1:3510 N UNIVERSITY ST STE A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3510 N UNIVERSITY ST STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1346
Practice Address - Country:US
Practice Address - Phone:203-215-4687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty