Provider Demographics
NPI:1770614331
Name:DEFAZIO, PETER A (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:MRS
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:DEFAZIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:279 3RD AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6205
Mailing Address - Country:US
Mailing Address - Phone:732-222-1533
Mailing Address - Fax:732-222-7715
Practice Address - Street 1:279 3RD AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6205
Practice Address - Country:US
Practice Address - Phone:732-222-1533
Practice Address - Fax:732-222-7715
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ172391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice