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General NPI Number Information
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NPI Number | 1588236897
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Entity Type | Individual
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Provider Name | COSMO AUGUST VIVIRITO DMD
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Gender | Male
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Dates
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Enumeration Date | 07/15/2021
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Last Update Date | 07/15/2021
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Provider Practice Location Address
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Address Line | 2210 DEAN ST STE J1
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City | ST CHARLES
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State | IL
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Zip | 60175-1059
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Country | US
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Telephone | 630-377-9008
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Fax |
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Provider Business Mailing Address
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Address Line | 39W595 ABBEY GLEN CT.
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City | ST.CHARLES
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State | IL
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Zip | 60176
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Country | US
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Telephone | 847-714-3149
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Fax |
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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 | O19.033076
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License Number State | IL
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