Provider Demographics
NPI:1225150261
Name:ACOSTA SMILE
Entity Type:Organization
Organization Name:ACOSTA SMILE
Other - Org Name:ACOSTA SMILE, LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DEJESUS
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-889-6622
Mailing Address - Street 1:101 S BONANZA AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-6789
Mailing Address - Country:US
Mailing Address - Phone:520-870-5957
Mailing Address - Fax:
Practice Address - Street 1:4323 E 5TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2088
Practice Address - Country:US
Practice Address - Phone:520-889-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD52351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty