Provider Demographics
NPI:1255495370
Name:DESTEFANO, ANTHONY (DMD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:DESTEFANO
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 1:6101 GRACE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-6003
Mailing Address - Country:US
Mailing Address - Phone:919-571-2484
Mailing Address - Fax:919-571-2486
Practice Address - Street 1:6101 GRACE PARK DR
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-6003
Practice Address - Country:US
Practice Address - Phone:919-571-2484
Practice Address - Fax:919-571-2486
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036173122300000X
NC8692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist