Provider Demographics
NPI:1912120684
Name:KOSTLAN, ERNEST LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:LYNN
Last Name:KOSTLAN
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 1:275 VICTORIA
Mailing Address - Street 2:2E
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-631-1420
Mailing Address - Fax:949-548-8844
Practice Address - Street 1:275 VICTORIA
Practice Address - Street 2:2E
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627
Practice Address - Country:US
Practice Address - Phone:949-631-1420
Practice Address - Fax:949-548-8844
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB1180401OtherDENTICAL