Provider Demographics
NPI:1689837825
Name:COSTELLO, JOHN E (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:COSTELLO
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 1:779 SUMMER ISLE LN
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60010-5414
Mailing Address - Country:US
Mailing Address - Phone:847-259-1111
Mailing Address - Fax:
Practice Address - Street 1:1640 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3985
Practice Address - Country:US
Practice Address - Phone:847-259-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23412-875122300000X
IL19-A-12900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist