MEDICARE: ANTHONY J. DESTEFANO, DMD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8692	NC

General Provider Information

NPI Number	:	1821351784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTHONY J. DESTEFANO, DMD, PA

Provider Business Mailing Address
First Line	:	6101 GRACE PARK DR
Second Line	:
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-6003
Country	:	US
Telephone Number	:	919-571-2484
Fax Number	:	919-571-2486

Provider Business Practice Location Address
First Line	:	6101 GRACE PARK DR
Second Line	:
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-6003
Country	:	US
Telephone Number	:	919-571-2484
Fax Number	:	919-571-2486

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. ANTHONY JASON DESTEFANO
Credential	:	D.M.D.
Telephone Number	:	919-723-7461

Provider Enumeration Date	:	06/15/2012
Last Update Date	:	06/15/2012

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