Provider Demographics
NPI:1417757915
Name:PROFESSIONAL DENTAL SPECIALTIES
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PICHE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-389-7177
Mailing Address - Street 1:17236 MUNSTER LN
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-4608
Mailing Address - Country:US
Mailing Address - Phone:319-389-7177
Mailing Address - Fax:
Practice Address - Street 1:1900 SPRING RD STE 205
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1479
Practice Address - Country:US
Practice Address - Phone:630-573-0369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty