Provider Demographics
NPI:1194976712
Name:ADVANCED DENTAL AESTHETICS
Entity type:Organization
Organization Name:ADVANCED DENTAL AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-748-8450
Mailing Address - Street 1:733 BLOOMFIELD AVE.
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-748-8450
Mailing Address - Fax:973-748-8934
Practice Address - Street 1:400 MAIN ST.
Practice Address - Street 2:
Practice Address - City:BEDMINSTER
Practice Address - State:NJ
Practice Address - Zip Code:07921
Practice Address - Country:US
Practice Address - Phone:908-901-9001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ17416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty