Healthcare Provider Details

I. General information

NPI: 1235432162
Provider Name (Legal Business Name): ANTONINO CRIVELLO DMD, MS, FRCD(C)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 LOCUST ST SUITE 200
PASADENA CA
91101-4455
US

IV. Provider business mailing address

747 LOCUST ST SUITE 200
PASADENA CA
91101-4455
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-5361
  • Fax: 626-796-3857
Mailing address:
  • Phone: 626-796-5361
  • Fax: 626-796-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number59815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: