Provider Demographics
NPI:1306227129
Name:ANTHONY DICOSTANZO DDS PC
Entity Type:Organization
Organization Name:ANTHONY DICOSTANZO DDS PC
Other - Org Name:SMILES BY DOCTOR D
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANANGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-865-3303
Mailing Address - Street 1:1123 JOLIET ST
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1926
Mailing Address - Country:US
Mailing Address - Phone:219-865-3303
Mailing Address - Fax:219-865-3244
Practice Address - Street 1:1123 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1926
Practice Address - Country:US
Practice Address - Phone:219-865-3303
Practice Address - Fax:219-865-3244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007851A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100168120AMedicaid