Provider Demographics
NPI:1235264227
Name:DIFAZIO, JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:DIFAZIO
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 1:107 MONMOUTH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1000
Mailing Address - Country:US
Mailing Address - Phone:732-542-0011
Mailing Address - Fax:732-542-9419
Practice Address - Street 1:107 MONMOUTH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1000
Practice Address - Country:US
Practice Address - Phone:732-542-0011
Practice Address - Fax:732-542-9419
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI012946001223P0700X
NJ31611223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1160430Medicaid
NJ520820Medicare ID - Type Unspecified
NJU24798Medicare UPIN