Provider Demographics
NPI:1245594050
Name:KOSTAL, MICHAEL TED (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TED
Last Name:KOSTAL
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 1:6632 W 10TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-9734
Mailing Address - Country:US
Mailing Address - Phone:970-353-4848
Mailing Address - Fax:
Practice Address - Street 1:6632 W 10TH ST STE 101
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-9734
Practice Address - Country:US
Practice Address - Phone:970-353-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist