Healthcare Provider Details

I. General information

NPI: 1689761488
Provider Name (Legal Business Name): JOHN M COSTLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN M COSTLEY DDS

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR.
SALT LAKE CITY UT
84148
US

IV. Provider business mailing address

1214 E. SHERWOOD DR
KAYSVILLE UT
84037
US

V. Phone/Fax

Practice location:
  • Phone: 801-584-1206
  • Fax:
Mailing address:
  • Phone: 801-546-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number275085-9923
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: