Provider Demographics
NPI:1174603013
Name:MISTRETTA, JOHN PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
Last Name:MISTRETTA
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 1:99 JESSE HILL JR DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303
Mailing Address - Country:US
Mailing Address - Phone:404-730-1471
Mailing Address - Fax:404-730-1475
Practice Address - Street 1:99 JESSE HILL JR DRIVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:404-730-1471
Practice Address - Fax:404-730-1475
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0089551223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00170717RMedicaid
GA00170717KMedicaid
GA00170717EMedicaid