Provider Demographics
NPI:1295767382
Name:MONTANEZ, MARIO (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:MONTANEZ
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 1:1014 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2659
Mailing Address - Country:US
Mailing Address - Phone:719-384-4614
Mailing Address - Fax:719-391-1625
Practice Address - Street 1:2436 S ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-2408
Practice Address - Country:US
Practice Address - Phone:719-391-2336
Practice Address - Fax:719-391-1625
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8039122300000X
NMDD2106122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1624385OtherUNITED CONCORDIA PROVIDER
CO33079072Medicaid