Provider Demographics
NPI:1104050665
Name:TEITELBUAM, AYLA ASA (DAC)
Entity type:Individual
Prefix:
First Name:AYLA
Middle Name:ASA
Last Name:TEITELBUAM
Suffix:
Gender:F
Credentials:DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CHESTNUT ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4169
Mailing Address - Country:US
Mailing Address - Phone:401-368-5940
Mailing Address - Fax:
Practice Address - Street 1:111 CHESTNUT ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4169
Practice Address - Country:US
Practice Address - Phone:401-368-5940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDA00298171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist