MEDICARE: DR. KIRILL VASILYEV 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	122300000X	Dentist	0401415489	VA
2	122300000X	Dentist	DS041131	PA

General Provider Information

NPI Number	:	1851838585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIRILL VASILYEV DDS

Provider Business Mailing Address
First Line	:	9733 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-3201
Country	:	US
Telephone Number	:	215-774-5050
Fax Number	:	215-437-7874

Provider Business Practice Location Address
First Line	:	9733 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-3201
Country	:	US
Telephone Number	:	215-774-5050
Fax Number	:	215-437-7874

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

Provider Enumeration Date	:	01/19/2017
Last Update Date	:	02/02/2017

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