Provider Demographics
NPI:1003254947
Name:PETER A DRAHOS DDS PC
Entity Type:Organization
Organization Name:PETER A DRAHOS DDS PC
Other - Org Name:PG FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST - PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:DRAHOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-516-1262
Mailing Address - Street 1:9118 OGDEN AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1974
Mailing Address - Country:US
Mailing Address - Phone:773-516-1262
Mailing Address - Fax:
Practice Address - Street 1:9118 OGDEN AVE UNIT B
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1974
Practice Address - Country:US
Practice Address - Phone:773-516-1262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty