Healthcare Provider Details

I. General information

NPI: 1215886734
Provider Name (Legal Business Name): LUIS ANTONIO COSTALES SR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8707
  • Fax: 910-907-6069
Mailing address:
  • Phone: 910-907-8707
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number15013
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: