Provider Demographics
NPI:1740433713
Name:MONTANA, MARK STEPHEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:MONTANA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7503
Mailing Address - Country:US
Mailing Address - Phone:480-820-2901
Mailing Address - Fax:480-820-2975
Practice Address - Street 1:2147 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7503
Practice Address - Country:US
Practice Address - Phone:480-820-2901
Practice Address - Fax:480-820-2975
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD39401223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics