MEDICARE: DR. THANOS T KRISTALLIS 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	DEN5317	DC
2	1223P0700X	Prosthodontics	DEN5317	DC

General Provider Information

NPI Number	:	1801118880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THANOS T KRISTALLIS DDS

Provider Business Mailing Address
First Line	:	1212 NEW YORK AVE NW
Second Line	:	STE 425
City	:	WASHINGTON
State	:	DC
Zip	:	20005-3987
Country	:	US
Telephone Number	:	202-737-1850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1212 NEW YORK AVE NW
Second Line	:	STE 425
City	:	WASHINGTON
State	:	DC
Zip	:	20005-3987
Country	:	US
Telephone Number	:	202-737-1850
Fax Number	:

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

Provider Enumeration Date	:	02/18/2010
Last Update Date	:	02/18/2010

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