Provider Demographics
NPI:1992497887
Name:COSTELLO RIORDAN, AMANDA CHRISTINE (DMD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:CHRISTINE
Last Name:COSTELLO RIORDAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 LAGRANGE ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3266
Mailing Address - Country:US
Mailing Address - Phone:339-203-1009
Mailing Address - Fax:
Practice Address - Street 1:540 GALLIVAN BLVD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02124-5400
Practice Address - Country:US
Practice Address - Phone:617-265-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18598121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty