Provider Demographics
NPI:1801583570
Name:PREMIER DENTAL GROUP PERSONAL CORPORATION
Entity type:Organization
Organization Name:PREMIER DENTAL GROUP PERSONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:AMODIO
Authorized Official - Last Name:BRUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-308-9929
Mailing Address - Street 1:183 N ADDISON AVE APT 216
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S WEST ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5021
Practice Address - Country:US
Practice Address - Phone:630-665-0650
Practice Address - Fax:708-484-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty