Eric Thomas Sudholt, D.M.D.

Primary specialty

DentistTaxonomy code 122300000X

License

019028324 Issued in IL

Practice address

838 W Glen Ave
Peoria, IL 61614-4835

Phone

(309) 691-1990

NPI assigned

Feb 18, 2011

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Mar 4, 2016 through Mar 4, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Pine Glen Dental Group, LTD

  • General Practice Dentistry
  • Peoria, IL
  • NPI 1053677765
  NPD (past)
• Pine Glen Dental Group, LTD

  • General Practice Dentistry
  • Peoria, IL
  • NPI 1659589299
  NPD (past)

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

{
    "created_epoch": "1297987200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1297987200000",
    "number": "1467759944",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "838 W GLEN AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616144835",
            "telephone_number": "309-691-1990"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "838 W GLEN AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616144835",
            "telephone_number": "309-691-1990"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUDHOLT",
        "first_name": "ERIC",
        "middle_name": "THOMAS",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-02-18",
        "last_updated": "2011-02-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019028324",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Carla Veronica Sturdivant, COTA
• Debra Littleton Sturm, PT
• Ronald J Suarez, O.D.
• Bhuvaneswari Subramanian
• Tamarra Lynn Subyantoro, APN
• Nicole Marie Sudholt, D.M.D.
• Daniel Jack Sudrzynski, DO
• Chasity C Suggs, PMHNP-BC
• Thomas Hyung Jun Suh, DO
• Stephanie Ann Sullivan, D.N.P., C.R.N.A.

• Dentist in Peoria, IL
• Providers in Peoria, IL by specialty
• Dentist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 18, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.