MEDICARE: MAIA MONTOYA DDS INC

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	1223G0001X	General Practice Dentistry	53469	CA

General Provider Information

NPI Number	:	1578944484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIA MONTOYA DDS INC

Provider Business Mailing Address
First Line	:	2706 W JEFFERSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-3321
Country	:	US
Telephone Number	:	323-734-9333
Fax Number	:

Provider Business Practice Location Address
First Line	:	2706 W JEFFERSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-3321
Country	:	US
Telephone Number	:	323-734-9333
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	MAIA MONTOYA
Credential	:
Telephone Number	:	213-725-6323

Provider Enumeration Date	:	06/16/2015
Last Update Date	:	06/16/2015

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