MEDICARE: DR. ANTONINO CRIVELLO DMD, MS, FRCD(C)

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	1223P0300X	Periodontics	59815	CA

General Provider Information

NPI Number	:	1235432162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTONINO CRIVELLO DMD, MS, FRCD(C)

Provider Business Mailing Address
First Line	:	747 LOCUST ST
Second Line	:	SUITE 200
City	:	PASADENA
State	:	CA
Zip	:	91101-4455
Country	:	US
Telephone Number	:	626-796-5361
Fax Number	:	626-796-3857

Provider Business Practice Location Address
First Line	:	747 LOCUST ST
Second Line	:	SUITE 200
City	:	PASADENA
State	:	CA
Zip	:	91101-4455
Country	:	US
Telephone Number	:	626-796-5361
Fax Number	:	626-796-3857

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

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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