Provider Demographics
NPI:1407889546
Name:LETIZIA, VIVIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:
Last Name:LETIZIA
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 1:2 MAVERICK RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498
Mailing Address - Country:US
Mailing Address - Phone:845-679-2421
Mailing Address - Fax:845-679-3235
Practice Address - Street 1:2 MAVERICK RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498
Practice Address - Country:US
Practice Address - Phone:845-679-2421
Practice Address - Fax:845-679-3235
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0388191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
038819OtherLICENSE