Provider Demographics
NPI:1033229372
Name:MONTALBANO, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MONTALBANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 E AIRPORT AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4832
Mailing Address - Country:US
Mailing Address - Phone:225-925-2118
Mailing Address - Fax:
Practice Address - Street 1:429 E AIRPORT AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4832
Practice Address - Country:US
Practice Address - Phone:225-925-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA31831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1831832Medicaid