Healthcare Provider Details

I. General information

NPI: 1114133113
Provider Name (Legal Business Name): CARLOS SANTANA MONTALVO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 ADAMS AVE STE 209
SAN DIEGO CA
92116-1367
US

IV. Provider business mailing address

2700 ADAMS AVE STE 209
SAN DIEGO CA
92116-1367
US

V. Phone/Fax

Practice location:
  • Phone: 619-647-4599
  • Fax: 888-323-3119
Mailing address:
  • Phone: 619-647-4599
  • Fax: 888-323-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number31862
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: