MEDICARE: DR. PETER STANEK D.D.S.

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1518220508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER STANEK D.D.S.

Provider Business Mailing Address
First Line	:	2945 N HALSTED ST
Second Line	:	#2
City	:	CHICAGO
State	:	IL
Zip	:	60657-5149
Country	:	US
Telephone Number	:	414-531-5191
Fax Number	:

Provider Business Practice Location Address
First Line	:	2945 N HALSTED ST
Second Line	:	#2
City	:	CHICAGO
State	:	IL
Zip	:	60657-5149
Country	:	US
Telephone Number	:	414-531-5191
Fax Number	:

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

Provider Enumeration Date	:	06/24/2012
Last Update Date	:	06/24/2012

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