=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639306822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL A. CHIULLI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2009
-----------------------------------------------------
Last Update Date | 06/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 S RENTON VILLAGE PL TRITON TOWERS ONE, SUITE 610
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-389-9995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 S RENTON VILLAGE PL TRITON TOWERS ONE, SUITE 610
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-389-9995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DE60209786
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6389
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------