Provider Demographics
NPI:1861593014
Name:DISTEFANO, SCOTT EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:EDWARD
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 1:1201 PINE TREE RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-3154
Mailing Address - Country:US
Mailing Address - Phone:903-759-4607
Mailing Address - Fax:903-759-3626
Practice Address - Street 1:1201 PINE TREE RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-3154
Practice Address - Country:US
Practice Address - Phone:903-759-4607
Practice Address - Fax:903-759-3626
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice