Provider Demographics
NPI:1669728812
Name:COSTELLO, MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
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 1:40 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2249
Mailing Address - Country:US
Mailing Address - Phone:978-774-8181
Mailing Address - Fax:
Practice Address - Street 1:40 POPLAR ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2249
Practice Address - Country:US
Practice Address - Phone:978-774-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18560111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice