Provider Demographics
NPI:1831106541
Name:COSTELLO, EDMUND J (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:J
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1698 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1240
Mailing Address - Country:US
Mailing Address - Phone:617-327-9656
Mailing Address - Fax:781-769-0599
Practice Address - Street 1:1698 CENTRE ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-1240
Practice Address - Country:US
Practice Address - Phone:617-327-9656
Practice Address - Fax:781-769-0599
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA107641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics