Provider Demographics
NPI:1538558408
Name:VITIELLO, MARYLENE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARYLENE
Middle Name:
Last Name:VITIELLO
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 1:1525 E 55TH ST STE 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5512
Mailing Address - Country:US
Mailing Address - Phone:773-947-9994
Mailing Address - Fax:773-947-8281
Practice Address - Street 1:1525 E 55TH ST STE 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615
Practice Address - Country:US
Practice Address - Phone:773-947-9994
Practice Address - Fax:773-947-8281
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021001441122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist