MEDICARE: PRESIDENTIAL DENTAL

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1194917013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESIDENTIAL DENTAL

Provider Business Mailing Address
First Line	:	564 W WASHINGTON BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-2509
Country	:	US
Telephone Number	:	312-902-3131
Fax Number	:

Provider Business Practice Location Address
First Line	:	564 W WASHINGTON BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-2509
Country	:	US
Telephone Number	:	312-902-3131
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. PETER A MICHALAK
Credential	:	DDS
Telephone Number	:	312-902-3131

Provider Enumeration Date	:	08/14/2007
Last Update Date	:	01/28/2014

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Directions to “PRESIDENTIAL DENTAL ” Practice Location

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