Provider Demographics
NPI:1144321399
Name:COSTELLA, ANTHONY G (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:G
Last Name:COSTELLA
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 1:1600 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1878
Mailing Address - Country:US
Mailing Address - Phone:415-453-0642
Mailing Address - Fax:415-459-6392
Practice Address - Street 1:1600 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1878
Practice Address - Country:US
Practice Address - Phone:415-453-0642
Practice Address - Fax:415-459-6392
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist