Provider Demographics
NPI:1336239565
Name:DISTEFANO, JOHN NORMAN JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NORMAN
Last Name:DISTEFANO
Suffix:JR
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 1:150 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2295
Mailing Address - Country:US
Mailing Address - Phone:860-633-1635
Mailing Address - Fax:860-633-1758
Practice Address - Street 1:150 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2295
Practice Address - Country:US
Practice Address - Phone:860-633-1635
Practice Address - Fax:860-633-1758
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT65061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice