Provider Demographics
NPI:1235783622
Name:VALDIVIA MONTOYA, LUIS FERNANDO (DDS)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:VALDIVIA MONTOYA
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 1:17427 LAKE WISTERIA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-9524
Mailing Address - Country:US
Mailing Address - Phone:228-239-6685
Mailing Address - Fax:
Practice Address - Street 1:282 BIG LAKE RD APT 59
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-3708
Practice Address - Country:US
Practice Address - Phone:228-239-6685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA72721223G0001X
390200000X
MS10001-231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program