Provider Demographics
NPI:1528194057
Name:COSTELLO, THOMAS T (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T
Last Name:COSTELLO
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 1:1 PAUL LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:KY
Mailing Address - Zip Code:41001-1123
Mailing Address - Country:US
Mailing Address - Phone:859-635-4184
Mailing Address - Fax:
Practice Address - Street 1:1 PAUL LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:KY
Practice Address - Zip Code:41001-1123
Practice Address - Country:US
Practice Address - Phone:859-635-4184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice