Provider Demographics
NPI:1952452047
Name:MT. PROSPECT DENTAL EXCELLENCE, LTD
Entity Type:Organization
Organization Name:MT. PROSPECT DENTAL EXCELLENCE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-259-1111
Mailing Address - Street 1:1640 N. ARLINGTON HEIGHTS RD.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004
Mailing Address - Country:US
Mailing Address - Phone:847-259-1111
Mailing Address - Fax:847-259-2222
Practice Address - Street 1:1640 N. ARLINGTON HEIGHTS RD.
Practice Address - Street 2:SUITE 201
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004
Practice Address - Country:US
Practice Address - Phone:847-259-1111
Practice Address - Fax:847-259-2222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A12900261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center