Provider Demographics
NPI:1902816226
Name:COSTANZA, CRAIG ALFRED (DMD)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ALFRED
Last Name:COSTANZA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BATEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:781-284-2090
Mailing Address - Fax:
Practice Address - Street 1:48 NEWHALL ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:781-284-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist