Provider Demographics
NPI:1376565580
Name:COSTELLO, ROBERT VANCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:VANCE
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1911 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4433
Mailing Address - Country:US
Mailing Address - Phone:337-233-5532
Mailing Address - Fax:337-233-6799
Practice Address - Street 1:1911 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4433
Practice Address - Country:US
Practice Address - Phone:337-233-5532
Practice Address - Fax:337-233-6799
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA56301223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice