Healthcare Provider Details

I. General information

NPI: 1720070311
Provider Name (Legal Business Name): FERNANDO L COSTAS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2TR510 VIA ADELINA VILLA FONTANA
CAROLINA PR
00983-3864
US

IV. Provider business mailing address

96 CALLE GARDENIA CIUDAD JARDIN
CAROLINA PR
00987-2207
US

V. Phone/Fax

Practice location:
  • Phone: 787-762-0045
  • Fax: 787-750-1460
Mailing address:
  • Phone: 787-762-0045
  • Fax: 787-750-1460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1132
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: