Healthcare Provider Details

I. General information

NPI: 1215290044
Provider Name (Legal Business Name): JARED A MONTANO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 W AZTEC AVE
GALLUP NM
87301-6302
US

IV. Provider business mailing address

214 W AZTEC AVE
GALLUP NM
87301-6302
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-4457
  • Fax:
Mailing address:
  • Phone: 505-863-4457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3676
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: