Provider Demographics
NPI:1467607218
Name:MONTOYA PEDIATRIC DENTISTRY LLC DBA SAN TAN PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:MONTOYA PEDIATRIC DENTISTRY LLC DBA SAN TAN PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MONTOYA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-457-1693
Mailing Address - Street 1:2510 E HUNT HWY
Mailing Address - Street 2:STE. 29
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85243-5206
Mailing Address - Country:US
Mailing Address - Phone:480-457-1693
Mailing Address - Fax:480-457-1321
Practice Address - Street 1:2510 E HUNT HWY
Practice Address - Street 2:STE. 29
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85243-5206
Practice Address - Country:US
Practice Address - Phone:480-457-1693
Practice Address - Fax:480-457-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ73841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1407045636Medicaid