Provider Demographics
NPI:1720156003
Name:PONTIKIS, PETER GUS (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:GUS
Last Name:PONTIKIS
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 1:7151 W GUNNISON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HARWOOD HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60706-3800
Mailing Address - Country:US
Mailing Address - Phone:708-867-4436
Mailing Address - Fax:708-867-4435
Practice Address - Street 1:7151 W GUNNISON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HARWOOD HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60706-3800
Practice Address - Country:US
Practice Address - Phone:708-867-4436
Practice Address - Fax:708-867-4435
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190208711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice