Provider Demographics
NPI:1932399680
Name:COSTES, MARK A (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:COSTES
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 1:432 BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5613
Mailing Address - Country:US
Mailing Address - Phone:928-636-1565
Mailing Address - Fax:928-636-1164
Practice Address - Street 1:432 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5613
Practice Address - Country:US
Practice Address - Phone:928-636-1565
Practice Address - Fax:928-636-1164
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD56341223G0001X
CA63591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice