Provider Demographics
NPI:1871740472
Name:VIVIRITO, ROSE M (DDS)
Entity type:Individual
Prefix:DR
First Name:ROSE
Middle Name:M
Last Name:VIVIRITO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 DEAN ST
Mailing Address - Street 2:STE J1
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175
Mailing Address - Country:US
Mailing Address - Phone:630-377-9007
Mailing Address - Fax:630-377-9112
Practice Address - Street 1:2210 DEAN ST
Practice Address - Street 2:STE J1
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175
Practice Address - Country:US
Practice Address - Phone:630-377-9007
Practice Address - Fax:630-377-9112
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0217991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice