Provider Demographics
NPI:1407889306
Name:COSTA, SHANE RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:RYAN
Last Name:COSTA
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 1:1626 APRICOT CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4404
Mailing Address - Country:US
Mailing Address - Phone:703-956-9097
Mailing Address - Fax:703-391-2097
Practice Address - Street 1:1950 ROLAND CLARKE PL
Practice Address - Street 2:SUITE 450
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1414
Practice Address - Country:US
Practice Address - Phone:703-391-2600
Practice Address - Fax:703-391-2097
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014109111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice