Provider Demographics
NPI:1164650198
Name:MONTANDON, RICHARD JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:MONTANDON
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 1:1859 N LAKEWOOD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2661
Mailing Address - Country:US
Mailing Address - Phone:208-818-6527
Mailing Address - Fax:
Practice Address - Street 1:1859 N LAKEWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2661
Practice Address - Country:US
Practice Address - Phone:208-818-6527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60688067122300000X
PADS0391191223D0004X
WAGA606907731223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No122300000XDental ProvidersDentist