Provider Demographics
NPI:1295265320
Name:GONTARZ, PETER (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:GONTARZ
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 1:525 LEXINGTON LANDING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-1749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 NW PLAZA DR STE 524
Practice Address - Street 2:
Practice Address - City:SAINT ANN
Practice Address - State:MO
Practice Address - Zip Code:63074-2220
Practice Address - Country:US
Practice Address - Phone:573-751-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017017918122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist