Provider Demographics
NPI:1164604740
Name:PETRAKOS, DIMITRA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:DIMITRA
Middle Name:
Last Name:PETRAKOS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2702
Mailing Address - Country:US
Mailing Address - Phone:708-425-1134
Mailing Address - Fax:708-423-3779
Practice Address - Street 1:2803 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2702
Practice Address - Country:US
Practice Address - Phone:708-425-1134
Practice Address - Fax:708-423-3779
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist