MEDICARE: DR. MARIO MONTANEZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	8039	CO
2	122300000X	Dentist	DD2106	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1624385	OTHER	CO	UNITED CONCORDIA PROVIDER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295767382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIO MONTANEZ DDS

Provider Business Mailing Address
First Line	:	1014 W 11TH ST
Second Line	:
City	:	LA JUNTA
State	:	CO
Zip	:	81050-2659
Country	:	US
Telephone Number	:	719-384-4614
Fax Number	:	719-391-1625

Provider Business Practice Location Address
First Line	:	2436 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-2408
Country	:	US
Telephone Number	:	719-391-2336
Fax Number	:	719-391-1625

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	07/09/2007

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