Provider Demographics
NPI:1811443153
Name:COSTA, BREANNA MICHELE (DDS)
Entity type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:MICHELE
Last Name:COSTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 WESTLAND GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-5306
Mailing Address - Country:US
Mailing Address - Phone:423-596-3118
Mailing Address - Fax:
Practice Address - Street 1:264 S PETERS RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-5203
Practice Address - Country:US
Practice Address - Phone:865-539-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN102941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice