Healthcare Provider Details

I. General information

NPI: 1174349864
Provider Name (Legal Business Name): KARLA MONTENEGRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W AVENUE K STE 105
LANCASTER CA
93534-6429
US

IV. Provider business mailing address

2739 WANDOO RD
PALMDALE CA
93551-6150
US

V. Phone/Fax

Practice location:
  • Phone: 661-723-1111
  • Fax:
Mailing address:
  • Phone: 619-576-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number111056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: