Healthcare Provider Details

I. General information

NPI: 1588636310
Provider Name (Legal Business Name): MAX PAUL MONCAYO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 ALMA REAL DR STE T4
PACIFIC PALISADES CA
90272-3743
US

IV. Provider business mailing address

3515 SAN JOAQUIN PLZ
NEWPORT BEACH CA
92660-5971
US

V. Phone/Fax

Practice location:
  • Phone: 310-459-0014
  • Fax:
Mailing address:
  • Phone: 909-908-9660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDD5229
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number53926
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number00205024
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: