Healthcare Provider Details

I. General information

NPI: 1538327200
Provider Name (Legal Business Name): THOMAS V DISTEFANO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MOUNTAINVIEW BLVD STE 205
BASKING RIDGE NJ
07920-3453
US

IV. Provider business mailing address

2333 MORRIS AVE SUITE D105
UNION NJ
07083
US

V. Phone/Fax

Practice location:
  • Phone: 908-604-0200
  • Fax: 908-686-6301
Mailing address:
  • Phone: 908-686-5277
  • Fax: 908-686-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI01562000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: