Provider Demographics
NPI:1598854556
Name:KOSTYAL, LARRY A (DMD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:KOSTYAL
Suffix:
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 1:125 N FRANKLIN DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-5892
Mailing Address - Country:US
Mailing Address - Phone:724-222-2256
Mailing Address - Fax:724-222-9384
Practice Address - Street 1:125 N FRANKLIN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-5892
Practice Address - Country:US
Practice Address - Phone:724-222-2256
Practice Address - Fax:724-222-9384
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS016965L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice