MEDICARE: DR. TERRY KRISTALLIS DMD

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	1000559	DC

General Provider Information

NPI Number	:	1447475819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY KRISTALLIS DMD

Provider Business Mailing Address
First Line	:	910 17TH ST NW
Second Line	:	SUITE 108
City	:	WASHINGTON
State	:	DC
Zip	:	20006-2601
Country	:	US
Telephone Number	:	202-887-1909
Fax Number	:	202-887-0417

Provider Business Practice Location Address
First Line	:	910 17TH ST NW
Second Line	:	SUITE 108
City	:	WASHINGTON
State	:	DC
Zip	:	20006-2601
Country	:	US
Telephone Number	:	202-887-1909
Fax Number	:	202-887-0417

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

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	09/20/2010

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