Healthcare Provider Details

I. General information

NPI: 1700720133
Provider Name (Legal Business Name): SOPHIA COSTELLO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2566 LAWRENCEVILLE SUWANEE RD
SUWANEE GA
30024-2537
US

IV. Provider business mailing address

2566 LAWRENCEVILLE SUWANEE RD
SUWANEE GA
30024-2537
US

V. Phone/Fax

Practice location:
  • Phone: 678-714-2380
  • Fax:
Mailing address:
  • Phone: 678-714-2380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124152
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: