1760855225 NPI number — LISA COSTELLO DENTAL HYGIENIST

Table of content: LISA COSTELLO DENTAL HYGIENIST (NPI 1760855225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760855225 NPI number — LISA COSTELLO DENTAL HYGIENIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTELLO
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DENTAL HYGIENIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760855225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
326 N. FERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND HAVEN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-846-2701
Provider Business Mailing Address Fax Number:
616-246-8009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
326 N. FERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND HAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-846-2701
Provider Business Practice Location Address Fax Number:
616-246-8009
Provider Enumeration Date:
11/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  2902011931 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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