Provider Demographics
NPI:1083716864
Name:MONTILLO, ALFONSO GERARDO (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:GERARDO
Last Name:MONTILLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2501
Mailing Address - Country:US
Mailing Address - Phone:617-630-1954
Mailing Address - Fax:617-969-7827
Practice Address - Street 1:420 WASHINGTON ST
Practice Address - Street 2:SUITE# 101
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4755
Practice Address - Country:US
Practice Address - Phone:781-848-2422
Practice Address - Fax:781-848-9922
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA183641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice