Provider Demographics
NPI:1194381418
Name:MONTICELLO, REBECCA (DDS, MS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MONTICELLO
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 GRAND RIDGE CT NE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7043
Mailing Address - Country:US
Mailing Address - Phone:616-364-1700
Mailing Address - Fax:
Practice Address - Street 1:1750 GRAND RIDGE CT NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7043
Practice Address - Country:US
Practice Address - Phone:616-364-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016001731223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics