Provider Demographics
NPI:1538327200
Name:DISTEFANO, THOMAS V (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:V
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 1:2333 MORRIS AVE
Mailing Address - Street 2:SUITE D105
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083
Mailing Address - Country:US
Mailing Address - Phone:908-686-5277
Mailing Address - Fax:908-686-6301
Practice Address - Street 1:25 MOUNTAINVIEW BLVD STE 205
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-3453
Practice Address - Country:US
Practice Address - Phone:908-604-0200
Practice Address - Fax:908-686-6301
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01562000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist