Provider Demographics
NPI:1336985076
Name:AFFINITY DENTAL PEORIA LLC
Entity type:Organization
Organization Name:AFFINITY DENTAL PEORIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DURSHANAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-215-4687
Mailing Address - Street 1:3510 N UNIVERSITY ST STE C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1348
Mailing Address - Country:US
Mailing Address - Phone:309-271-7777
Mailing Address - Fax:309-324-5777
Practice Address - Street 1:3510 N UNIVERSITY ST STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1348
Practice Address - Country:US
Practice Address - Phone:309-271-7777
Practice Address - Fax:309-324-5777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-02
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental