Provider Demographics
NPI:1164864765
Name:COSTIS, JAMES A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:COSTIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5456 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1225
Mailing Address - Country:US
Mailing Address - Phone:773-631-5693
Mailing Address - Fax:773-631-0058
Practice Address - Street 1:5456 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1225
Practice Address - Country:US
Practice Address - Phone:773-631-5693
Practice Address - Fax:773-631-0058
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist