Healthcare Provider Details

I. General information

NPI: 1790887941
Provider Name (Legal Business Name): KENNETH S COSTA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N WASHINGTON AVE
DUNELLEN NJ
08812-1246
US

IV. Provider business mailing address

8 JOHN STEVENS ROAD
WHITEHOUSE ST NJ
08889
US

V. Phone/Fax

Practice location:
  • Phone: 732-968-1115
  • Fax: 908-534-4027
Mailing address:
  • Phone: 908-534-1127
  • Fax: 908-534-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11853
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: