Professional Dental Alliance of Grove Dental Specialty LLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

Legal business name

PROFESSIONAL DENTAL ALLIANCE OF GROVE DENTAL SPECIALTY LLC

Doing business as

Grove Dental

Practice address

160 E Boughton Rd
Bolingbrook, IL 60440-2014

Phone

(630) 410-1766

NPI assigned

Mar 17, 2020

Last updated

Apr 28, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Amanda Kurtz

Title

Credentialing Specialist

Phone

(724) 698-2058

Specialties & licenses 1

Addresses

Other names 1

• Grove Dental Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1584403200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1619568000000",
    "number": "1215563762",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 715279",
            "city": "CINCINNATI",
            "state": "OH",
            "postal_code": "452715279"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "160 E BOUGHTON RD",
            "city": "BOLINGBROOK",
            "state": "IL",
            "postal_code": "604402014",
            "telephone_number": "630-410-1766"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL DENTAL ALLIANCE OF GROVE DENTAL SPECIALTY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-03-17",
        "last_updated": "2021-04-28",
        "certification_date": "2021-04-28",
        "status": "A",
        "authorized_official_last_name": "KURTZ",
        "authorized_official_first_name": "AMANDA",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "724-698-2058"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Grove Dental",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Grove Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Dental Clinic/Center in Bolingbrook, IL
• Providers in Bolingbrook, IL by specialty
• Dental Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.