MEDICARE: MR. DENO STAVROS CHRYSOSTOM DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2015	SC

General Provider Information

NPI Number	:	1477623791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENO STAVROS CHRYSOSTOM DMD

Provider Business Mailing Address
First Line	:	3308 PLATT SPRINGS RD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29170
Country	:	US
Telephone Number	:	803-796-7934
Fax Number	:	803-796-1357

Provider Business Practice Location Address
First Line	:	3308 PLATT SPRINGS RD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29170
Country	:	US
Telephone Number	:	803-796-7934
Fax Number	:	803-796-1357

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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