Provider Demographics
NPI:1588221717
Name:MUSTAZZA, JOSEPH LEONARD (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:LEONARD
Last Name:MUSTAZZA
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 ESSEX CT
Mailing Address - Street 2:
Mailing Address - City:PERKASIE
Mailing Address - State:PA
Mailing Address - Zip Code:18944-1297
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0421541223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA28996539OtherDRIVERS LICENSE NUMBER