Provider Demographics
NPI:1053421214
Name:PHILO-COSTELLO, DEBORAH ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:ANN
Last Name:PHILO-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 1:15106 E 113TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-5285
Mailing Address - Country:US
Mailing Address - Phone:918-371-7369
Mailing Address - Fax:
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5047
Practice Address - Country:US
Practice Address - Phone:918-342-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA74711223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health