Provider Demographics
NPI:1063306348
Name:KOSTENKO, JACKIE JANET (DDS)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:JANET
Last Name:KOSTENKO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 NW 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-4953
Mailing Address - Country:US
Mailing Address - Phone:617-257-5669
Mailing Address - Fax:
Practice Address - Street 1:1201 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1624
Practice Address - Country:US
Practice Address - Phone:305-575-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty