Provider Demographics
NPI:1902054281
Name:DRS COSTIS P.C.
Entity type:Organization
Organization Name:DRS COSTIS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:COSTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-631-5693
Mailing Address - Street 1:5456 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1225
Mailing Address - Country:US
Mailing Address - Phone:773-631-5693
Mailing Address - Fax:773-631-0058
Practice Address - Street 1:5456 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1225
Practice Address - Country:US
Practice Address - Phone:773-631-5693
Practice Address - Fax:773-631-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-022-163122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty