Healthcare Provider Details

I. General information

NPI: 1053644880
Provider Name (Legal Business Name): BASILIOS C COSTARAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BILL C COSTARAS DDS

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10214 N TATUM BLVD STE A1100
PHOENIX AZ
85028-4243
US

IV. Provider business mailing address

10214 N TATUM BLVD STE A1100
PHOENIX AZ
85028-4243
US

V. Phone/Fax

Practice location:
  • Phone: 602-992-1486
  • Fax: 602-992-6604
Mailing address:
  • Phone: 602-992-1486
  • Fax: 602-992-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD008677
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberD008677
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD008677
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: