Provider Demographics
NPI:1942458328
Name:MONTOYA, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MONTOYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 BASELINE RD STE 310
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2669
Mailing Address - Country:US
Mailing Address - Phone:303-443-1895
Mailing Address - Fax:
Practice Address - Street 1:4770 BASELINE RD STE 310
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303
Practice Address - Country:US
Practice Address - Phone:303-443-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9350122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1629239827OtherNPI