Provider Demographics
NPI:1952380412
Name:CHIARAVALLI, PETER CARMEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:CARMEN
Last Name:CHIARAVALLI
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 1:1500 W SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-1380
Mailing Address - Country:US
Mailing Address - Phone:517-485-5738
Mailing Address - Fax:517-485-0169
Practice Address - Street 1:1500 W SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-1380
Practice Address - Country:US
Practice Address - Phone:517-485-5738
Practice Address - Fax:517-485-0169
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4033251Medicaid