Provider Demographics
NPI:1588236897
Name:VIVIRITO, COSMO AUGUST (DMD)
Entity Type:Individual
Prefix:DR
First Name:COSMO
Middle Name:AUGUST
Last Name:VIVIRITO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39W595 ABBEY GLEN CT.
Mailing Address - Street 2:
Mailing Address - City:ST.CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60176
Mailing Address - Country:US
Mailing Address - Phone:847-714-3149
Mailing Address - Fax:
Practice Address - Street 1:2210 DEAN ST STE J1
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1059
Practice Address - Country:US
Practice Address - Phone:630-377-9008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO19.033076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty