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General NPI Number Information
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NPI Number | 1104910942
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Entity Type | Individual
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Provider Name | DANIEL E DISTASI D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 700 BROADWAY STE 64
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City | WESTWOOD
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State | NJ
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Zip | 07675-1674
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Country | US
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Telephone | 201-666-1300
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Fax | 201-666-2055
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Provider Business Mailing Address
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Address Line | 200 W 57TH ST STE 410
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City | NEW YORK
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State | NY
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Zip | 10019-3211
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 22DI01442602
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License Number State | NJ
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