Provider Demographics
NPI:1780804369
Name:COSTANZO, CORY J (DDS)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:J
Last Name:COSTANZO
Suffix:
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 1:1922 N GRAYBARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-9590
Mailing Address - Country:US
Mailing Address - Phone:559-297-4086
Mailing Address - Fax:
Practice Address - Street 1:7104 N FRESNO ST
Practice Address - Street 2:101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2970
Practice Address - Country:US
Practice Address - Phone:559-439-2147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA502341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics