Provider Demographics
NPI:1982789681
Name:MISTRETTA, CHARLES J (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
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 1:1911 RICHMOND AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3913
Mailing Address - Country:US
Mailing Address - Phone:718-370-1911
Mailing Address - Fax:
Practice Address - Street 1:1911 RICHMOND AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3913
Practice Address - Country:US
Practice Address - Phone:718-370-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0313401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice