Provider Demographics
NPI:1366541211
Name:GALLOS, PETE ANDREW (DDS)
Entity type:Individual
Prefix:MR
First Name:PETE
Middle Name:ANDREW
Last Name:GALLOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12426 S. VAN DYKE RD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585
Mailing Address - Country:US
Mailing Address - Phone:815-254-6700
Mailing Address - Fax:815-254-5995
Practice Address - Street 1:12426 S. VAN DYKE RD SUITE B
Practice Address - Street 2:HERITAGE GROVE FAMILY DENTAL
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585
Practice Address - Country:US
Practice Address - Phone:815-254-6700
Practice Address - Fax:815-254-5995
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-025501122300000X
IL0190255011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist