Provider Demographics
NPI:1639449267
Name:HERO DENTAL OF ESSEX PC-RONALD B MONTANO DDS
Entity Type:Organization
Organization Name:HERO DENTAL OF ESSEX PC-RONALD B MONTANO DDS
Other - Org Name:ADVENTURE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:URBANOZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-323-2362
Mailing Address - Street 1:2221 E BIJOU ST
Mailing Address - Street 2:STE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-955-8896
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:1346 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-3423
Practice Address - Country:US
Practice Address - Phone:410-406-3006
Practice Address - Fax:410-406-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD052827700Medicaid