Basic Information
Provider Information | |||||||||
NPI: | 1669661997 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONTOYA | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5005 N PIEDRAS ST | ||||||||
Address2: | USA DENTAC | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799205001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155685935 | ||||||||
FaxNumber: | 9155685174 | ||||||||
Practice Location | |||||||||
Address1: | 5005 N PIEDRAS ST | ||||||||
Address2: | USA DENTAC | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799205001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155685935 | ||||||||
FaxNumber: | 9155685174 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2007 | ||||||||
LastUpdateDate: | 05/26/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0023562 | TX | Y |   | Dental Providers | Dentist |   |
No ID Information.