Provider Demographics
NPI:1740397975
Name:DITULLIO, DONALD M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:M
Last Name:DITULLIO
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 1:20445 PROSPECT RD STE 2
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4663
Mailing Address - Country:US
Mailing Address - Phone:408-996-2323
Mailing Address - Fax:
Practice Address - Street 1:20445 PROSPECT RD STE 2
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4663
Practice Address - Country:US
Practice Address - Phone:408-996-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice