Provider Demographics
NPI:1689761488
Name:COSTLEY, JOHN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:COSTLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:COSTLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1214 E. SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037
Mailing Address - Country:US
Mailing Address - Phone:801-546-0400
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DR.
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148
Practice Address - Country:US
Practice Address - Phone:801-584-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275085-99231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics