Healthcare Provider Details

I. General information

NPI: 1093633133
Provider Name (Legal Business Name): ST. JOHN PREMIER DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10271 CALUMET AVE. #103
ST. JOHN IN
46373
US

IV. Provider business mailing address

10271 CALUMET AVE. #103
ST. JOHN IN
46373
US

V. Phone/Fax

Practice location:
  • Phone: 219-627-7000
  • Fax: 219-627-9627
Mailing address:
  • Phone: 219-627-7000
  • Fax: 219-627-9627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER WILLIAM STRAKA
Title or Position: OWNER
Credential: DMD
Phone: 219-627-7000