Provider Demographics
NPI:1407144793
Name:PETAR S TOFOVIC PC
Entity Type:Organization
Organization Name:PETAR S TOFOVIC PC
Other - Org Name:WHITE DENTAL STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETAR
Authorized Official - Middle Name:S
Authorized Official - Last Name:TOFOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:773-609-4483
Mailing Address - Street 1:1414 W CHICAGO AVE
Mailing Address - Street 2:STORE/UNIT 1C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5403
Mailing Address - Country:US
Mailing Address - Phone:773-609-4483
Mailing Address - Fax:
Practice Address - Street 1:1414 W CHICAGO AVE
Practice Address - Street 2:STORE/UNIT 1C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5403
Practice Address - Country:US
Practice Address - Phone:773-609-4483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01927481261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental