Provider Demographics
NPI:1851705834
Name:COSTA, MICHAEL J JR (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:COSTA
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 S PETERS RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-5203
Mailing Address - Country:US
Mailing Address - Phone:865-539-1776
Mailing Address - Fax:865-539-1585
Practice Address - Street 1:264 S PETERS RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-5203
Practice Address - Country:US
Practice Address - Phone:865-539-1776
Practice Address - Fax:865-539-1858
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9738122300000X
TN10644122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist