Provider Demographics
NPI:1093969834
Name:COSTELLO, JOHN ROBERT (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:COSTELLO
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 1:400 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-1733
Mailing Address - Country:US
Mailing Address - Phone:401-849-8433
Mailing Address - Fax:
Practice Address - Street 1:400 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-1733
Practice Address - Country:US
Practice Address - Phone:401-849-8433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1818122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist