MEDICARE: DR. NIKOLA PETROVIC DMD

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	019037166	IL

General Provider Information

NPI Number	:	1215861182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NIKOLA PETROVIC DMD

Provider Business Mailing Address
First Line	:	1507 N VETERANS PKWY STE 2
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-0916
Country	:	US
Telephone Number	:	309-490-8089
Fax Number	:

Provider Business Practice Location Address
First Line	:	1507 N VETERANS PKWY STE 2
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-0916
Country	:	US
Telephone Number	:	309-490-8089
Fax Number	:

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

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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