Provider Demographics
NPI:1932865292
Name:MONTES, ENRIQUE FERNANDEZ
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:FERNANDEZ
Last Name:MONTES
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:PO BOX 998375
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-6314
Mailing Address - Country:US
Mailing Address - Phone:684-256-2603
Mailing Address - Fax:
Practice Address - Street 1:#1 PETESA RD
Practice Address - Street 2:
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799
Practice Address - Country:US
Practice Address - Phone:684-699-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS4092C1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice