=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649618711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SHANE COSTA/LITTLE SMILES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2013
-----------------------------------------------------
Last Update Date | 06/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42395 RYAN RD SUITE 104
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20148-4863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-757-0833
-----------------------------------------------------
Fax | 703-757-0833
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42395 RYAN RD SUITE 104
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20148-4863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-757-0833
-----------------------------------------------------
Fax | 703-757-0833
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | DR. SHANE R COSTA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 703-757-0833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401410911
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------