Provider Demographics
NPI:1154576171
Name:COSTELLO, ELINA (DDS)
Entity type:Individual
Prefix:DR
First Name:ELINA
Middle Name:
Last Name:COSTELLO
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 1:32749 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-1122
Mailing Address - Country:US
Mailing Address - Phone:248-543-7070
Mailing Address - Fax:248-626-6635
Practice Address - Street 1:32749 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MI
Practice Address - Zip Code:48025-1122
Practice Address - Country:US
Practice Address - Phone:248-626-6635
Practice Address - Fax:248-539-0303
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0140411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice