Provider Demographics
NPI:1235385980
Name:COSTELLO, CHANDA J (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHANDA
Middle Name:J
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10211 SW PARK WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5009
Mailing Address - Country:US
Mailing Address - Phone:503-203-6978
Mailing Address - Fax:
Practice Address - Street 1:10211 SW PARK WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5009
Practice Address - Country:US
Practice Address - Phone:503-203-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD91331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice