Provider Demographics
NPI:1609187244
Name:MONTANO, STACEY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:M
Last Name:MONTANO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3901 GEORGIA ST NE BLDG G
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1387
Mailing Address - Country:US
Mailing Address - Phone:505-888-3112
Mailing Address - Fax:505-883-4651
Practice Address - Street 1:3901 GEORGIA ST NE BLDG G
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1387
Practice Address - Country:US
Practice Address - Phone:505-888-3112
Practice Address - Fax:505-883-4651
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist