Provider Demographics
NPI:1114994043
Name:VITERI, JOSE GERARDO (RDH)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:GERARDO
Last Name:VITERI
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 NW CACHE RD
Mailing Address - Street 2:APT. 7 C
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3336
Mailing Address - Country:US
Mailing Address - Phone:580-354-9181
Mailing Address - Fax:
Practice Address - Street 1:605 RANDOLPH RD
Practice Address - Street 2:COWAN DENTAL CLINIC
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-1201
Practice Address - Country:US
Practice Address - Phone:580-442-5925
Practice Address - Fax:580-442-7147
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH009281124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist