Provider Demographics
NPI:1497811236
Name:TOMASELLI, PETER M (DDS,FICOI,FACE,FDOCS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:TOMASELLI
Suffix:
Gender:M
Credentials:DDS,FICOI,FACE,FDOCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1420
Mailing Address - Country:US
Mailing Address - Phone:312-664-2100
Mailing Address - Fax:312-664-0234
Practice Address - Street 1:437 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1420
Practice Address - Country:US
Practice Address - Phone:312-664-2100
Practice Address - Fax:312-664-0234
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist