Basic Information
| Provider Information | |||||||||
| NPI: | 1063790954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHIU | ||||||||
| FirstName: | ELLIOT | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | N. CAMPUS BUSINESS OFFICE /ATT: R SOARES | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562525 | ||||||||
| FaxNumber: | 4014566742 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 PEACE ST | ||||||||
| Address2: | ST. JOSEPH PEDI. DENTAL | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029071510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014564441 | ||||||||
| FaxNumber: | 4014564089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2011 | ||||||||
| LastUpdateDate: | 07/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | LD0073 | RI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | LD0073 | 01 | RI | LICENSE | OTHER |