Provider Demographics
NPI:1194917013
Name:PRESIDENTIAL DENTAL
Entity type:Organization
Organization Name:PRESIDENTIAL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MICHALAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-902-3131
Mailing Address - Street 1:564 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2509
Mailing Address - Country:US
Mailing Address - Phone:312-902-3131
Mailing Address - Fax:
Practice Address - Street 1:564 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-2509
Practice Address - Country:US
Practice Address - Phone:312-902-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty