Provider Demographics
NPI:1780797340
Name:MONTEJO, VISAYAS BORGONIA (DMD)
Entity type:Individual
Prefix:DR
First Name:VISAYAS
Middle Name:BORGONIA
Last Name:MONTEJO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 SANTA MONICA BLVD.
Mailing Address - Street 2:SUITE #111
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029
Mailing Address - Country:US
Mailing Address - Phone:323-664-9363
Mailing Address - Fax:323-668-2851
Practice Address - Street 1:4855 SANTA MONICA BLVD.
Practice Address - Street 2:VISAYAS B. MONTEJO, DMD SUITE #111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029
Practice Address - Country:US
Practice Address - Phone:323-664-9363
Practice Address - Fax:323-668-2851
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44950122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
522658Medicare UPIN