Healthcare Provider Details

I. General information

NPI: 1417113440
Provider Name (Legal Business Name): MICHELLE DISTEFANO MICHELLE DISTEFANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE VELASQUEZ-DURON D.M.D

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10410 TITANIUM ST
BAKERSFIELD CA
93311-9537
US

IV. Provider business mailing address

10410 TITANIUM ST
BAKERSFIELD CA
93311-9537
US

V. Phone/Fax

Practice location:
  • Phone: 661-412-2143
  • Fax:
Mailing address:
  • Phone: 661-412-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59818
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02383000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: