Provider Demographics
NPI:1356100366
Name:LONDONO MONCADA, SERGIO
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:LONDONO MONCADA
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 1:601 ALBANY ST UNIT 404
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2790
Mailing Address - Country:US
Mailing Address - Phone:240-370-6452
Mailing Address - Fax:
Practice Address - Street 1:920 S CURLEY ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4824
Practice Address - Country:US
Practice Address - Phone:240-370-6452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18402122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program