MEDICARE: RONALD A. VITULLO, DDS, LLC

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	30-022225	OH

General Provider Information

NPI Number	:	1114009594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RONALD A. VITULLO, DDS, LLC

Provider Business Mailing Address
First Line	:	1911 N FAIRFIELD RD
Second Line	:	SUITE 130
City	:	BEAVERCREEK
State	:	OH
Zip	:	45432-2762
Country	:	US
Telephone Number	:	937-426-2253
Fax Number	:	937-426-7891

Provider Business Practice Location Address
First Line	:	1911 N FAIRFIELD RD
Second Line	:	SUITE 130
City	:	BEAVERCREEK
State	:	OH
Zip	:	45432-2762
Country	:	US
Telephone Number	:	937-426-2253
Fax Number	:	937-426-7891

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. RONALD ANTHONY VITULLO
Credential	:	D.D.S.
Telephone Number	:	937-426-2253

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	09/10/2007

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