Provider Demographics
NPI:1467469155
Name:PELUSA, PHILIP M (DDS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
Last Name:PELUSA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7017 W ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2201
Mailing Address - Country:US
Mailing Address - Phone:773-586-2788
Mailing Address - Fax:773-229-8400
Practice Address - Street 1:7017 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2201
Practice Address - Country:US
Practice Address - Phone:773-586-2788
Practice Address - Fax:773-229-8400
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1915560122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist