Provider Demographics
NPI:1649492851
Name:DECOSTA, JAMES ANTHONY (DMD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ANTHONY
Last Name:DECOSTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19300 SW BOONES FERRY RD
Mailing Address - Street 2:#8
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:503-692-0650
Mailing Address - Fax:503-692-6787
Practice Address - Street 1:19300 SW BOONES FERRY RD
Practice Address - Street 2:#8
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-692-0650
Practice Address - Fax:503-692-6787
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist