Healthcare Provider Details

I. General information

NPI: 1245658798
Provider Name (Legal Business Name): LA COSTA DENTAL OF KOSTORYZ PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4506 KOSTORYZ RD
CORPUS CHRISTI TX
78415-5023
US

IV. Provider business mailing address

8150 SPRINGWOOD DR # 150B
IRVING TX
75063-5810
US

V. Phone/Fax

Practice location:
  • Phone: 817-531-3500
  • Fax: 817-531-3501
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22334
License Number StateTX

VIII. Authorized Official

Name: DR. TIEN DINH PHAN
Title or Position: DENTIST
Credential: DMD
Phone: 817-531-3500