Provider Demographics
NPI:1568752897
Name:CRACCHIOLO, PETER THOMAS JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:THOMAS
Last Name:CRACCHIOLO
Suffix:JR
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 1:417 OAK RUN CT
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-3549
Mailing Address - Country:US
Mailing Address - Phone:313-570-8375
Mailing Address - Fax:
Practice Address - Street 1:31700 TELEGRAPH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-3407
Practice Address - Country:US
Practice Address - Phone:248-433-6000
Practice Address - Fax:248-433-3650
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020423122300000X
IL018001806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist