Provider Demographics
NPI:1144252529
Name:COSTA, MICHAEL E (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:COSTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 C ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3949
Mailing Address - Country:US
Mailing Address - Phone:907-277-1440
Mailing Address - Fax:907-277-1436
Practice Address - Street 1:100 SLOCUM DR
Practice Address - Street 2:
Practice Address - City:KING COVE
Practice Address - State:AK
Practice Address - Zip Code:99612
Practice Address - Country:US
Practice Address - Phone:907-497-2311
Practice Address - Fax:907-497-2310
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1382122300000X
ORD7867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022868Medicaid
943096772OtherFEDERAL TAX ID
AK1382OtherALASKA DENTAL LICENSE
ORD7867OtherSTATE LICENSE