Provider Demographics
NPI:1972602803
Name:DISTEFANO, GARY ROBERT (DDS)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2268
Mailing Address - Country:US
Mailing Address - Phone:517-546-8983
Mailing Address - Fax:517-546-1422
Practice Address - Street 1:112 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-2268
Practice Address - Country:US
Practice Address - Phone:517-546-8983
Practice Address - Fax:517-546-1422
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID011030122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1954760090Medicare UPIN