MEDICARE: IMPLANT DENTAL ARTS

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	019027304	IL
2	1223G0001X	General Practice Dentistry	BT 0632403	IL

General Provider Information

NPI Number	:	1265764419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPLANT DENTAL ARTS

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	:

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	:

Authorized Official
Title or Position	:	PRACTICE OWNER
Name	:	DR. PETER MICHAEL TOMASELLI
Credential	:	D.D.S.
Telephone Number	:	312-664-2100

Provider Enumeration Date	:	02/12/2010
Last Update Date	:	02/12/2010

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Directions to “IMPLANT DENTAL ARTS ” Practice Location

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