NPIMap

Organization Active NPI

Prairie Avenue Dental Associates, Inc.

  • General Practice Dentistry
  • Hebron, IL
National Provider Identifier
1245428234
Registry record updated Oct 4, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
PRAIRIE AVENUE DENTAL ASSOCIATES, INC.
Practice address
12016 Prairie Ave
Post Office Box 75
Hebron, IL 60034-8892
Phone
(815) 648-4095
Fax
(815) 648-2881
NPI assigned
Oct 4, 2007
Last updated
Oct 4, 2007By the provider in NPPES
Organization subpart
Yes
Parent organization
RENEE E. SCHULTZ DIETZAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 4, 2007

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

Authorized official

Name
Dr. Renee E. Dietz, D.M.D.
Title
Owner
Phone
(815) 648-4095

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X IL Primary

Addresses

Primary practice location

12016 Prairie Ave
Post Office Box 75
Hebron, IL 60034-8892

Mailing address

12016 Prairie Ave
Post Office Box 75
Hebron, IL 60034-8892
Phone (815) 648-4095

Other names 1

  • Renee Schultz Dietz Former legal business name

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1191456000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1191456000000",
    "number": "1245428234",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12016 PRAIRIE AVE",
            "address_2": "POST OFFICE BOX 75",
            "city": "HEBRON",
            "state": "IL",
            "postal_code": "600348892",
            "telephone_number": "815-648-4095",
            "fax_number": "815-648-2881"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12016 PRAIRIE AVE",
            "address_2": "POST OFFICE BOX 75",
            "city": "HEBRON",
            "state": "IL",
            "postal_code": "600348892",
            "telephone_number": "815-648-4095",
            "fax_number": "815-648-2881"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRAIRIE AVENUE DENTAL ASSOCIATES, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "RENEE E. SCHULTZ DIETZ",
        "enumeration_date": "2007-10-04",
        "last_updated": "2007-10-04",
        "status": "A",
        "authorized_official_last_name": "DIETZ",
        "authorized_official_first_name": "RENEE",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "815-648-4095",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Renee Schultz Dietz",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Hebron, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2007; 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.