Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 22DI0198470 | NJ |
N | 1223S0112X | Oral and Maxillofacial Surgeon | DI19847 | NJ |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 22DI0198470 | NJ |
NPI | 1336220466 |
---|---|
Provider Name | Dr. Michael A Costello |
First Address | Maywood, NJ 07607 |
Second Address | Maywood, NJ 07607 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2006 |
Last Update Date | 18/11/2016 |