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General NPI Number Information
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NPI Number | 1538327200
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Entity Type | Individual
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Provider Name | THOMAS V DISTEFANO DMD
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Gender | Male
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Dates
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Enumeration Date | 05/29/2008
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Last Update Date | 08/25/2020
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Provider Practice Location Address
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Address Line | 25 MOUNTAINVIEW BLVD STE 205
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City | BASKING RIDGE
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State | NJ
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Zip | 07920-3453
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Country | US
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Telephone | 908-604-0200
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Fax | 908-686-6301
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Provider Business Mailing Address
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Address Line | 2333 MORRIS AVE SUITE D105
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City | UNION
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State | NJ
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Zip | 07083
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Country | US
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Telephone | 908-686-5277
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Fax | 908-686-6301
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI01562000
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License Number State | NJ
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