Provider Demographics
NPI:1346126182
Name:STATELINE DENTISTRY PC
Entity type:Organization
Organization Name:STATELINE DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-385-4140
Mailing Address - Street 1:3700 IL ROUTE 173
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60071-9614
Mailing Address - Country:US
Mailing Address - Phone:815-701-6411
Mailing Address - Fax:
Practice Address - Street 1:3700 IL ROUTE 173
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IL
Practice Address - Zip Code:60071-9614
Practice Address - Country:US
Practice Address - Phone:815-701-6411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty