Healthcare Provider Details

I. General information

NPI: 1114836699
Provider Name (Legal Business Name): LUIS GERARDO MONTOYA DAVILA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 WESTERN AVE
BOSTON MA
02135-1007
US

IV. Provider business mailing address

200 QUARRY HILLS DR APT 1234
QUINCY MA
02169-3825
US

V. Phone/Fax

Practice location:
  • Phone: 617-208-1656
  • Fax:
Mailing address:
  • Phone: 857-347-1289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL101844
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: