Provider Demographics
NPI:1114503802
Name:COSTANZA, ELANA DANIELLE
Entity Type:Individual
Prefix:
First Name:ELANA
Middle Name:DANIELLE
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 S NEWARK CT
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-5219
Mailing Address - Country:US
Mailing Address - Phone:720-366-2409
Mailing Address - Fax:
Practice Address - Street 1:220 E ROGERS RD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6027
Practice Address - Country:US
Practice Address - Phone:303-697-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.00204972122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist