Provider Demographics
NPI:1295087377
Name:COSTELLO, SHERRIE ANN (RDH)
Entity type:Individual
Prefix:
First Name:SHERRIE
Middle Name:ANN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63188-0551
Mailing Address - Country:US
Mailing Address - Phone:314-814-8557
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:1717 BIDDLE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-3454
Practice Address - Country:US
Practice Address - Phone:314-814-8581
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012017508124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist