Provider Demographics
NPI:1669597340
Name:BLAZEK, PETER E (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:E
Last Name:BLAZEK
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 1:812 ROCKBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-8265
Mailing Address - Country:US
Mailing Address - Phone:630-985-5000
Mailing Address - Fax:
Practice Address - Street 1:2839 83RD ST
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-5612
Practice Address - Country:US
Practice Address - Phone:630-985-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-164561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice