MEDICARE: DR. KRYSTAL MATTOX 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	122300000X	Dentist	0401416209	VA
2	1223G0001X	General Practice Dentistry	0401416209	VA

General Provider Information

NPI Number	:	1629555883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRYSTAL MATTOX DDS

Provider Business Mailing Address
First Line	:	180 E BELT BLVD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-1204
Country	:	US
Telephone Number	:	804-292-3011
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 E BELT BLVD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-1204
Country	:	US
Telephone Number	:	804-783-2505
Fax Number	:

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

Provider Enumeration Date	:	07/20/2018
Last Update Date	:	06/07/2022

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