Provider Demographics
NPI:1790853323
Name:KOSTKO, MARK ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:KOSTKO
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 1:55 EAST LOOP RD
Mailing Address - Street 2:STE 201
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:630-653-8899
Mailing Address - Fax:630-653-8957
Practice Address - Street 1:55 EAST LOOP RD
Practice Address - Street 2:STE 201
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-653-8899
Practice Address - Fax:630-653-8957
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist