Provider Demographics
NPI:1043480551
Name:COSTA, MICHAEL LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:COSTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 HART BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2613
Mailing Address - Country:US
Mailing Address - Phone:718-442-3982
Mailing Address - Fax:
Practice Address - Street 1:62 HART BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2613
Practice Address - Country:US
Practice Address - Phone:718-442-3982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053358-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist