Provider Demographics
NPI:1124027214
Name:COSTON, CARLA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:L
Last Name:COSTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 FAR WEST BLVD
Mailing Address - Street 2:STE. 340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3194
Mailing Address - Country:US
Mailing Address - Phone:512-795-0128
Mailing Address - Fax:512-795-8393
Practice Address - Street 1:3410 FAR WEST BLVD
Practice Address - Street 2:STE. 340
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3194
Practice Address - Country:US
Practice Address - Phone:512-795-0128
Practice Address - Fax:512-795-8393
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
TX164891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice