Provider Demographics
NPI:1316765142
Name:KOSTELIC & ASSOCIATES 2, PLLC
Entity type:Organization
Organization Name:KOSTELIC & ASSOCIATES 2, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTELIC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:336-577-1583
Mailing Address - Street 1:1480 RYMCO DR STE A
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3072
Mailing Address - Country:US
Mailing Address - Phone:336-725-9580
Mailing Address - Fax:
Practice Address - Street 1:1480 RYMCO DR STE A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3072
Practice Address - Country:US
Practice Address - Phone:336-725-9580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental