Individual
DR. SHANE RYAN COSTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S
Contact information
Practice address
1950 ROLAND CLARKE PL, SUITE 450, RESTON, VA 20191-1414
(703) 391-2600
(703) 391-2097
Mailing address
1626 APRICOT CT, RESTON, VA 20190-4404
(703) 956-9097
(703) 391-2097
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
0401410911
VA
Other
Enumeration date
07/07/2006
Last updated
07/08/2007
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