Provider Demographics
NPI:1912099730
Name:COSTELLOE, LUISA M (DDS)
Entity type:Individual
Prefix:MRS
First Name:LUISA
Middle Name:M
Last Name:COSTELLOE
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 1:40-16 ASTORIA BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11103
Mailing Address - Country:US
Mailing Address - Phone:718-937-3836
Mailing Address - Fax:718-937-3836
Practice Address - Street 1:40-16 ASTORIA BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11103
Practice Address - Country:US
Practice Address - Phone:718-937-3836
Practice Address - Fax:718-937-3836
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR044783122300000X
NY044783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01432062Medicaid