Provider Demographics
NPI:1023161304
Name:DESTEFANIS, PAUL M (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:DESTEFANIS
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 1:525 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1745
Mailing Address - Country:US
Mailing Address - Phone:262-782-5400
Mailing Address - Fax:
Practice Address - Street 1:1050 LEGION DR
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2230
Practice Address - Country:US
Practice Address - Phone:262-782-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice