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General NPI Number Information
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NPI Number | 1417113440
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Entity Type | Individual
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Provider Name | MICHELLE DISTEFANO MICHELLE DISTEFANO
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Gender | Female
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Dates
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Enumeration Date | 07/30/2008
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Last Update Date | 10/19/2010
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Provider Practice Location Address
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Address Line | 10410 TITANIUM ST
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City | BAKERSFIELD
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State | CA
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Zip | 93311-9537
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Country | US
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Telephone | 661-412-2143
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Fax |
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Provider Business Mailing Address
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Address Line | 10410 TITANIUM ST
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City | BAKERSFIELD
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State | CA
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Zip | 93311-9537
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Country | US
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Telephone | 661-412-2143
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22DI02383000
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 59818
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License Number State | CA
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