Basic Information
| Provider Information | |||||||||
| NPI: | 1114994043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VITERI | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | GERARDO | ||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5535 NW CACHE RD | ||||||||
| Address2: | APT. 7 C | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735053336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803549181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 605 RANDOLPH RD | ||||||||
| Address2: | COWAN DENTAL CLINIC | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735031201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804425925 | ||||||||
| FaxNumber: | 5804427147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH009281 | GA | Y | Dental Providers | Dental Hygienist |
No ID Information.