Provider Demographics
NPI:1659495307
Name:COSTA, MANUEL EMILIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:EMILIO
Last Name:COSTA
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 1:7110 MIAMI LAKES WAY SOUTH
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014
Mailing Address - Country:US
Mailing Address - Phone:305-828-1156
Mailing Address - Fax:305-953-0707
Practice Address - Street 1:791 E 48TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1959
Practice Address - Country:US
Practice Address - Phone:305-769-0252
Practice Address - Fax:305-953-0707
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 87361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071495000Medicaid