MEDICARE: DR. JOHN DESTEFON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN18561	FL

General Provider Information

NPI Number	:	1992947212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN DESTEFON DMD

Provider Business Mailing Address
First Line	:	7110 SOUTHGATE BLVD
Second Line	:
City	:	N. LAUDERDALE
State	:	FL
Zip	:	33068
Country	:	US
Telephone Number	:	954-724-8949
Fax Number	:	954-724-1185

Provider Business Practice Location Address
First Line	:	7110 SOUTHGATE BLVD
Second Line	:
City	:	N. LAUDERDALE
State	:	FL
Zip	:	33068
Country	:	US
Telephone Number	:	954-724-8949
Fax Number	:	954-724-1185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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