=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962659797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS COSTIS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2008
-----------------------------------------------------
Last Update Date | 08/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1792 S ARLINGTON HEIGHTS RD
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60005-3727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-806-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1792 S ARLINGTON HEIGHTS RD
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60005-3727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-806-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019019202
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------