Provider Demographics
NPI:1962663104
Name:COSTA, MATTHEW JOSEPH (DMDQ)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:COSTA
Suffix:
Gender:M
Credentials:DMDQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 GOVERNOR MARKHAM DR
Mailing Address - Street 2:
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1029
Mailing Address - Country:US
Mailing Address - Phone:610-558-3222
Mailing Address - Fax:
Practice Address - Street 1:316 W 4TH ST
Practice Address - Street 2:
Practice Address - City:QUARRYVILLE
Practice Address - State:PA
Practice Address - Zip Code:17566-1138
Practice Address - Country:US
Practice Address - Phone:717-786-2746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0375071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice