Provider Demographics
NPI:1851474142
Name:ANTONELLIS, PETER JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:ANTONELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 CHANGEBRIDGE RD
Mailing Address - Street 2:UNIT C 5-2
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9115
Mailing Address - Country:US
Mailing Address - Phone:973-227-1132
Mailing Address - Fax:
Practice Address - Street 1:170 CHANGEBRIDGE RD
Practice Address - Street 2:UNIT C 5-2
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9115
Practice Address - Country:US
Practice Address - Phone:973-227-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ130561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics