Provider Demographics
NPI:1649346297
Name:COSTLEY, KEVIN HUGH (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:HUGH
Last Name:COSTLEY
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 1:101 7TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377
Mailing Address - Country:US
Mailing Address - Phone:320-253-8241
Mailing Address - Fax:320-253-8625
Practice Address - Street 1:101 7TH STREET NORTH
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-253-8241
Practice Address - Fax:320-253-8625
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9122122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist