Provider Demographics
NPI:1508659624
Name:COSTELLO, CONNOR LUKE (DDS)
Entity type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:LUKE
Last Name:COSTELLO
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 1:2016 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5036
Mailing Address - Country:US
Mailing Address - Phone:318-387-5732
Mailing Address - Fax:
Practice Address - Street 1:2016 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5036
Practice Address - Country:US
Practice Address - Phone:318-387-5732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA76611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice