MEDICARE: DR. ROBERT VANCE COSTELLO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5630	LA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	5630	LA

General Provider Information

NPI Number	:	1376565580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT VANCE COSTELLO DDS

Provider Business Mailing Address
First Line	:	1911 W CONGRESS ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4433
Country	:	US
Telephone Number	:	337-233-5532
Fax Number	:	337-233-6799

Provider Business Practice Location Address
First Line	:	1911 W CONGRESS ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4433
Country	:	US
Telephone Number	:	337-233-5532
Fax Number	:	337-233-6799

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	11/15/2021

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