Healthcare Provider Details

I. General information

NPI: 1104910942
Provider Name (Legal Business Name): DANIEL E DISTASI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 BROADWAY STE 64
WESTWOOD NJ
07675-1674
US

IV. Provider business mailing address

200 W 57TH ST STE 410
NEW YORK NY
10019-3211
US

V. Phone/Fax

Practice location:
  • Phone: 201-666-1300
  • Fax: 201-666-2055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI01442602
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: