Provider Demographics
NPI:1962943290
Name:OPTIM DENTAL PEORIA-1 LLC
Entity type:Organization
Organization Name:OPTIM DENTAL PEORIA-1 LLC
Other - Org Name:
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:DDS
Authorized Official - Phone:217-303-5955
Mailing Address - Street 1:1200 W MAIN ST STE 9
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1218
Mailing Address - Country:US
Mailing Address - Phone:309-777-9777
Mailing Address - Fax:
Practice Address - Street 1:1200 W MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1218
Practice Address - Country:US
Practice Address - Phone:309-777-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty