MEDICARE: DR. PETER M TOMASELLI DDS,FICOI,FACE,FDOCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1497811236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER M TOMASELLI DDS,FICOI,FACE,FDOCS

Provider Business Mailing Address
First Line	:	437 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1420
Country	:	US
Telephone Number	:	312-664-2100
Fax Number	:	312-664-0234

Provider Business Practice Location Address
First Line	:	437 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1420
Country	:	US
Telephone Number	:	312-664-2100
Fax Number	:	312-664-0234

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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