Healthcare Provider Details

I. General information

NPI: 1063306348
Provider Name (Legal Business Name): JACKIE JANET KOSTENKO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 05/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST
MIAMI FL
33125-1624
US

IV. Provider business mailing address

3645 NW 36TH ST
MIAMI FL
33142-4953
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-7000
  • Fax:
Mailing address:
  • Phone: 617-257-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: