Provider Demographics
NPI:1164205076
Name:ACOSTA, PRYSCILLA
Entity Type:Individual
Prefix:
First Name:PRYSCILLA
Middle Name:
Last Name:ACOSTA
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 1:371 COMMONWEALTH AVE UNIT 409
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-1818
Mailing Address - Country:US
Mailing Address - Phone:619-623-5456
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3550
Practice Address - Country:US
Practice Address - Phone:619-623-5456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADL1860036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program