Provider Demographics
NPI:1790879047
Name:MISTRETTA, JOHN JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:MISTRETTA
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 1:15201 SHADY GROVE RD
Mailing Address - Street 2:# 101
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:301-840-0600
Mailing Address - Fax:301-840-0601
Practice Address - Street 1:15201 SHADY GROVE RD
Practice Address - Street 2:# 101
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-840-0600
Practice Address - Fax:301-840-0601
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD6428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist