Provider Demographics
NPI:1154486330
Name:FRY, PETER WALTER
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WALTER
Last Name:FRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 W PETERSON AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5713
Mailing Address - Country:US
Mailing Address - Phone:773-545-1414
Mailing Address - Fax:
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5713
Practice Address - Country:US
Practice Address - Phone:773-545-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL09-015486122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist