Healthcare Provider Details

I. General information

NPI: 1053421214
Provider Name (Legal Business Name): DEBORAH ANN PHILO-COSTELLO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S MOORE AVE
CLAREMORE OK
74017-5047
US

IV. Provider business mailing address

15106 E 113TH ST N
OWASSO OK
74055-5285
US

V. Phone/Fax

Practice location:
  • Phone: 918-342-6400
  • Fax:
Mailing address:
  • Phone: 918-371-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number7471
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: