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General NPI Number Information
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NPI Number | 1538558408
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Entity Type | Individual
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Provider Name | MARYLENE VITIELLO DDS
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Gender | Female
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Dates
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Enumeration Date | 01/15/2015
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Last Update Date | 05/24/2018
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Provider Practice Location Address
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Address Line | 1525 E 55TH ST STE 303
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City | CHICAGO
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State | IL
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Zip | 60615
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Country | US
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Telephone | 773-947-9994
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Fax | 773-947-8281
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Provider Business Mailing Address
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Address Line | 1525 E 55TH ST STE 303
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City | CHICAGO
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State | IL
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Zip | 60615-5512
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Country | US
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Telephone | 773-947-9994
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Fax | 773-947-8281
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 021001441
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 021001441
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License Number State | IL
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