Provider Demographics
NPI:1700027885
Name:ACOSTA, WINNISTHER-JOHN MADRIGAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:WINNISTHER-JOHN
Middle Name:MADRIGAL
Last Name:ACOSTA
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 1:1279 LINDA MAR SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-3347
Mailing Address - Country:US
Mailing Address - Phone:650-355-5159
Mailing Address - Fax:650-355-5759
Practice Address - Street 1:1279 LINDA MAR SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-3347
Practice Address - Country:US
Practice Address - Phone:650-355-5159
Practice Address - Fax:650-355-5759
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA574471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice