Healthcare Provider Details

I. General information

NPI: 1821364191
Provider Name (Legal Business Name): CHAYNE E COSTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6029 SHAFFER DR APT 1412
ALEXANDRIA VA
22310-2275
US

IV. Provider business mailing address

6029 SHAFFER DR
ALEXANDRIA VA
22310-2275
US

V. Phone/Fax

Practice location:
  • Phone: 224-522-0339
  • Fax:
Mailing address:
  • Phone: 224-522-0339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1001719
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number04041418627
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: