Provider Demographics
NPI:1336220466
Name:COSTELLO, MICHAEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:COSTELLO
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 1:949 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607
Mailing Address - Country:US
Mailing Address - Phone:201-712-5556
Mailing Address - Fax:201-712-9190
Practice Address - Street 1:949 SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607
Practice Address - Country:US
Practice Address - Phone:201-712-5556
Practice Address - Fax:201-712-5556
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI198471223S0112X
NJ22DI0198470204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery