Provider Demographics
NPI:1487382149
Name:MONTERROSO ZELAYA, LIDIA
Entity type:Individual
Prefix:
First Name:LIDIA
Middle Name:
Last Name:MONTERROSO ZELAYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 BOUNTY DR
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-2953
Mailing Address - Country:US
Mailing Address - Phone:925-360-4898
Mailing Address - Fax:
Practice Address - Street 1:1851 SUTTER ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2559
Practice Address - Country:US
Practice Address - Phone:925-827-2798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107669122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist