Provider Demographics
NPI:1578711016
Name:DACOSTA, KAI (DO)
Entity Type:Individual
Prefix:
First Name:KAI
Middle Name:
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:ME
Mailing Address - Zip Code:04667-0351
Mailing Address - Country:US
Mailing Address - Phone:207-853-0644
Mailing Address - Fax:207-853-2347
Practice Address - Street 1:9040 FITZSIMMONS DR
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1000
Practice Address - Country:US
Practice Address - Phone:253-968-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2155208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice