Provider Demographics
NPI:1417052556
Name:COSTELLO, WILLIAM JOHN III (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOHN
Last Name:COSTELLO
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 S 10TH ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1975
Mailing Address - Country:US
Mailing Address - Phone:267-240-1497
Mailing Address - Fax:
Practice Address - Street 1:7215 PASSYUNK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-1525
Practice Address - Country:US
Practice Address - Phone:215-336-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0368271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice