Provider Demographics
NPI:1548383359
Name:DESTITO, JOHN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:DESTITO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-5008
Mailing Address - Country:US
Mailing Address - Phone:315-336-9190
Mailing Address - Fax:315-336-3121
Practice Address - Street 1:206 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-5008
Practice Address - Country:US
Practice Address - Phone:315-336-9190
Practice Address - Fax:315-336-3121
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00596121Medicaid