Provider Demographics
NPI:1851705834
Name:COSTA, MICHAEL J JR
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:COSTA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D DENBN/NDC PSC 20130 315 MCHUGH BLVD
Mailing Address - Street 2:COMMANDING OFFICER
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0130
Mailing Address - Country:US
Mailing Address - Phone:910-451-2208
Mailing Address - Fax:910-451-8036
Practice Address - Street 1:2D DENBN/NDC PSC 20130 315 MCHUGH BLVD
Practice Address - Street 2:COMMANDING OFFICER
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0130
Practice Address - Country:US
Practice Address - Phone:910-451-2208
Practice Address - Fax:910-451-8036
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9738122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist