Provider Demographics
NPI:1114133113
Name:MONTALVO, CARLOS SANTANA (IDC)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:SANTANA
Last Name:MONTALVO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 ADAMS AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1367
Mailing Address - Country:US
Mailing Address - Phone:619-647-4599
Mailing Address - Fax:888-323-3119
Practice Address - Street 1:2700 ADAMS AVE STE 209
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1367
Practice Address - Country:US
Practice Address - Phone:619-647-4599
Practice Address - Fax:888-323-3119
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X
CA31862124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31862OtherBOARD OF DENTAL HYGIENE CALIFORNIA