Provider Demographics
NPI:1053929646
Name:COSTA, THIAGO SANTOS (DDS)
Entity type:Individual
Prefix:
First Name:THIAGO
Middle Name:SANTOS
Last Name:COSTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9259 W 121ST PL APT 121
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-2548
Mailing Address - Country:US
Mailing Address - Phone:919-434-1908
Mailing Address - Fax:
Practice Address - Street 1:9528 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-4058
Practice Address - Country:US
Practice Address - Phone:913-286-5189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61647122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist