Provider Demographics
NPI:1639706419
Name:DEFILIPPO, ANTHONY JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:DEFILIPPO
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 1:20-30 BEAVER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2244
Mailing Address - Country:US
Mailing Address - Phone:860-721-7428
Mailing Address - Fax:
Practice Address - Street 1:20-30 BEAVER RD STE 102
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2244
Practice Address - Country:US
Practice Address - Phone:860-721-7428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
000000000390200000X
CT132061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1508971557OtherNPI