Provider Demographics
NPI:1356554778
Name:DACOSTA, PERCIVAL FREDERICK (DDS)
Entity type:Individual
Prefix:DR
First Name:PERCIVAL
Middle Name:FREDERICK
Last Name:DACOSTA
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 1:2234 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-5627
Mailing Address - Country:US
Mailing Address - Phone:937-278-0891
Mailing Address - Fax:937-278-5179
Practice Address - Street 1:2234 SALEM AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-5627
Practice Address - Country:US
Practice Address - Phone:937-278-0891
Practice Address - Fax:937-278-5179
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30. 0159291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0371511Medicaid