Provider Demographics
NPI:1265764419
Name:IMPLANT DENTAL ARTS
Entity type:Organization
Organization Name:IMPLANT DENTAL ARTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TOMASELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-664-2100
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190273041223G0001X
ILBT 06324031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1336345974Medicare PIN
IL1497811236Medicare PIN