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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X0023562TXY Dental ProvidersDentist 

No ID Information.


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