Provider Demographics
NPI:1528246121
Name:COSTA, JOAO
Entity type:Individual
Prefix:
First Name:JOAO
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 MORTON ST
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2834
Mailing Address - Country:US
Mailing Address - Phone:617-533-2300
Mailing Address - Fax:617-533-2341
Practice Address - Street 1:351 PLEASANT LAKE AVE
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-1813
Practice Address - Country:US
Practice Address - Phone:508-778-5400
Practice Address - Fax:508-778-5401
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice