Provider Demographics
NPI:1245297951
Name:COSTA, LOUIS II (DMD, MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:COSTA
Suffix:II
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1306
Mailing Address - Country:US
Mailing Address - Phone:843-722-5904
Mailing Address - Fax:843-722-1564
Practice Address - Street 1:247 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1306
Practice Address - Country:US
Practice Address - Phone:843-722-5904
Practice Address - Fax:843-722-1564
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC52349Medicare UPIN