Provider Demographics
NPI:1972097251
Name:KOSTELIC, MATTHEW (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KOSTELIC
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 1:2265 LEWISVILLE CLEMMONS RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-7459
Mailing Address - Country:US
Mailing Address - Phone:336-577-1583
Mailing Address - Fax:
Practice Address - Street 1:2265 LEWISVILLE CLEMMONS RD STE A
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-7459
Practice Address - Country:US
Practice Address - Phone:336-577-1583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice