Provider Demographics
NPI:1063790954
Name:CHIU, ELLIOT (DMD)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:CHIU
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 1:825 CHALKSTONE AVE
Mailing Address - Street 2:N. CAMPUS BUSINESS OFFICE /ATT: R SOARES
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2525
Mailing Address - Fax:401-456-6742
Practice Address - Street 1:21 PEACE ST
Practice Address - Street 2:ST. JOSEPH PEDI. DENTAL
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1510
Practice Address - Country:US
Practice Address - Phone:401-456-4441
Practice Address - Fax:401-456-4089
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILD0073122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILD0073OtherLICENSE