MEDICARE: PETER GUS PONTIKIS 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	1223G0001X	General Practice Dentistry	019020871	IL

General Provider Information

NPI Number	:	1720156003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER GUS PONTIKIS D.D.S.

Provider Business Mailing Address
First Line	:	7151 W GUNNISON ST
Second Line	:	SUITE 100
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-3800
Country	:	US
Telephone Number	:	708-867-4436
Fax Number	:	708-867-4435

Provider Business Practice Location Address
First Line	:	7151 W GUNNISON ST
Second Line	:	SUITE 100
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-3800
Country	:	US
Telephone Number	:	708-867-4436
Fax Number	:	708-867-4435

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

Provider Enumeration Date	:	12/02/2006
Last Update Date	:	07/08/2007

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