Provider Demographics
NPI:1457392680
Name:COSTELLO, CHARLES RICHARD II
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:COSTELLO
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 PELLIS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-4506
Mailing Address - Country:US
Mailing Address - Phone:724-832-7200
Mailing Address - Fax:724-832-7227
Practice Address - Street 1:514 PELLIS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-4506
Practice Address - Country:US
Practice Address - Phone:724-832-7200
Practice Address - Fax:724-832-7227
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-019865-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice