Affinity Dental Peoria LLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

AFFINITY DENTAL PEORIA LLC

Doing business as

Affinity Family Dental Peoria

Practice address

3510 N University St Ste C
Peoria, IL 61604-1348

Phone

(309) 271-7777

Fax

(309) 324-5777

NPI assigned

Jul 2, 2024

Last updated

Nov 5, 2024By 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

Srinivas DurshanapalliNPI 1710265434

Title

President

Phone

(203) 215-4687

Specialties & licenses 2

Addresses

Other names 1

• Affinity Family Dental Peoria Doing business as

Locations

Practitioners 4

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.

• Srinivas Rao Durshanapalli

  • Dentist
  • Indianapolis, IN
  • NPI 1710265434
  NPD (past) Authorized official
• Veena Govardhan Dhoke, DMD

  • General Practice Dentistry
  • Peoria, IL
  • NPI 1730007162
  NPD (past)
• Pramod Tadakamalla, DDS

  • General Practice Dentistry
  • Peoria, IL
  • NPI 1629591854
  NPD (past)
• Surendra Reddy Mandapati, DDS

  • General Practice Dentistry
  • Northampton, MA
  • NPI 1649893470
  NPD (past)

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

{
    "created_epoch": "1719878400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730764800000",
    "number": "1336985076",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3510 N UNIVERSITY ST STE C",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616041348",
            "telephone_number": "309-271-7777",
            "fax_number": "309-324-5777"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3510 N UNIVERSITY ST STE C",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616041348",
            "telephone_number": "309-271-7777",
            "fax_number": "309-324-5777"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AFFINITY DENTAL PEORIA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-07-02",
        "last_updated": "2024-11-05",
        "certification_date": "2024-11-05",
        "status": "A",
        "authorized_official_last_name": "DURSHANAPALLI",
        "authorized_official_first_name": "SRINIVAS",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "203-215-4687"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Affinity Family Dental Peoria",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Affinity Family Dental Peoria",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Juanita Rodriguez Aguila-Corrales, MD

• General Practice Dentistry in Peoria, IL
• Providers in Peoria, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 5, 2024; 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.