Provider Demographics
NPI:1518920727
Name:DESTENO, COSMO VITO (DMD)
Entity Type:Individual
Prefix:DR
First Name:COSMO
Middle Name:VITO
Last Name:DESTENO
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 1:203 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07762-1023
Mailing Address - Country:US
Mailing Address - Phone:732-449-3518
Mailing Address - Fax:
Practice Address - Street 1:110 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2495
Practice Address - Country:US
Practice Address - Phone:973-972-4582
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1008818001223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics