MEDICARE: KRISTO, LTD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	3752	WI

General Provider Information

NPI Number	:	1073045860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRISTO, LTD

Provider Business Mailing Address
First Line	:	1600 CLEVELAND AVE
Second Line	:
City	:	MARINETTE
State	:	WI
Zip	:	54143-3923
Country	:	US
Telephone Number	:	715-735-7666
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 CLEVELAND AVE
Second Line	:
City	:	MARINETTE
State	:	WI
Zip	:	54143-3923
Country	:	US
Telephone Number	:	715-735-7666
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEVEN J KRISTO
Credential	:	DDS, MS
Telephone Number	:	715-835-5182

Provider Enumeration Date	:	03/30/2017
Last Update Date	:	03/30/2017

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