Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | DS029638L | PA |
NPI | 1457444705 |
---|---|
Provider Name | Dr. Bernard James Costello |
First Address | Presto, PA 15142-1069 |
Second Address | Pittsburgh, PA 15261-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2006 |
Last Update Date | 08/07/2007 |