Provider Demographics
NPI:1821215633
Name:PETLAK, ANDREW FRANK (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:FRANK
Last Name:PETLAK
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 1:121 S WILKE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1533
Mailing Address - Country:US
Mailing Address - Phone:847-255-0909
Mailing Address - Fax:847-255-1339
Practice Address - Street 1:121 S WILKE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1533
Practice Address - Country:US
Practice Address - Phone:847-255-0909
Practice Address - Fax:847-255-1339
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL003-019016812-021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice