Provider Demographics
NPI:1568531721
Name:COSTAGLI, BRUCE BLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:BLAS
Last Name:COSTAGLI
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 1:967 W GOLF RD
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-1329
Mailing Address - Country:US
Mailing Address - Phone:847-882-8989
Mailing Address - Fax:847-882-8941
Practice Address - Street 1:967 W GOLF RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-1329
Practice Address - Country:US
Practice Address - Phone:847-882-8989
Practice Address - Fax:847-882-8941
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice