MEDICARE: KEVIN CRISCITIELLO DDS

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	1223G0001X	General Practice Dentistry	14481	MD
2	1223G0001X	General Practice Dentistry	0401415867	VA

General Provider Information

NPI Number	:	1609007442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN CRISCITIELLO DDS

Provider Business Mailing Address
First Line	:	7834 FOREST HILL AVE STE 1
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-1974
Country	:	US
Telephone Number	:	804-272-2205
Fax Number	:	804-272-2111

Provider Business Practice Location Address
First Line	:	7834 FOREST HILL AVE STE 1
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-1974
Country	:	US
Telephone Number	:	804-272-2205
Fax Number	:	804-272-2111

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

Provider Enumeration Date	:	07/28/2009
Last Update Date	:	05/19/2021

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