Provider Demographics
NPI:1174663561
Name:VIVIT, EDWARD GERONIMO (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GERONIMO
Last Name:VIVIT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3338 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1247
Mailing Address - Country:US
Mailing Address - Phone:773-478-9393
Mailing Address - Fax:773-478-9303
Practice Address - Street 1:3338 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1247
Practice Address - Country:US
Practice Address - Phone:773-478-9393
Practice Address - Fax:773-478-9303
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190221921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice