Provider Demographics
NPI:1548350796
Name:KOSTYACK, GAYLE ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:ANN
Last Name:KOSTYACK
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 1:1201 HERITAGE CIR
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-3744
Mailing Address - Country:US
Mailing Address - Phone:918-762-6570
Mailing Address - Fax:918-762-3543
Practice Address - Street 1:1201 HERITAGE CIR
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-3744
Practice Address - Country:US
Practice Address - Phone:918-762-6570
Practice Address - Fax:918-762-3543
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0219701223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health