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General NPI Number Information
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NPI Number | 1194976712
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Entity Type | Organization
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Legal Business Name | ADVANCED DENTAL AESTHETICS
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Dates
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Enumeration Date | 10/01/2008
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Last Update Date | 10/01/2008
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Provider Practice Location Address
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Address Line | 400 MAIN ST.
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City | BEDMINSTER
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State | NJ
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Zip | 07921
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Country | US
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Telephone | 908-901-9001
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Fax |
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Provider Business Mailing Address
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Address Line | 733 BLOOMFIELD AVE.
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City | BLOOMFIELD
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State | NJ
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Zip | 07003
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Country | US
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Telephone | 973-748-8450
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Fax | 973-748-8934
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Authorized Official
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Title or Position | OWNER/VICE PRESIDENT
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Name | JOSEPH S. DISTEFANO
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Credential | DMD
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Telephone | 973-748-8450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 17416
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License Number State | NJ
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