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General NPI Number Information
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NPI Number | 1871764910
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Entity Type | Individual
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Provider Name | STACEY LYNNE COSTA RDH
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Gender | Female
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Dates
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Enumeration Date | 03/17/2008
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 2084 NE PROFESSIONAL CT
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City | BEND
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State | OR
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Zip | 97701-6077
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Country | US
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Telephone | 541-383-3005
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Fax |
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Provider Business Mailing Address
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Address Line | 18866 SHOSHONE RD
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City | BEND
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State | OR
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Zip | 97702-7923
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Country | US
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Telephone | 530-526-2415
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 23431
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | H7792
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License Number State | OR
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