Provider Demographics
NPI:1053644880
Name:COSTARAS, BASILIOS C (DDS)
Entity Type:Individual
Prefix:DR
First Name:BASILIOS
Middle Name:C
Last Name:COSTARAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BILL
Other - Middle Name:C
Other - Last Name:COSTARAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:874 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:874 BEACH RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-1018
Practice Address - Country:US
Practice Address - Phone:216-469-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH185741223G0001X
AZD0086771223G0001X
IL019.0275531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice