Provider Demographics
NPI:1093966616
Name:DISTEFANO, JOSEPH S (DMD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:S
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 BLOOMFIELD AVE.
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-748-8450
Mailing Address - Fax:973-748-8934
Practice Address - Street 1:733 BLOOMFIELD AVE.
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-748-8450
Practice Address - Fax:973-748-8934
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ17416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist