Provider Demographics
NPI:1245359801
Name:VITALE, MICHAEL JOSEPH (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:VITALE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PARK ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5412
Mailing Address - Country:US
Mailing Address - Phone:203-865-2874
Mailing Address - Fax:
Practice Address - Street 1:111 PARK ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5412
Practice Address - Country:US
Practice Address - Phone:203-865-2874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT73031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice