Healthcare Provider Details

I. General information

NPI: 1851308290
Provider Name (Legal Business Name): DIANNA R MONTOYA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 GOLF COURSE RD SE BLD A
RIO RANCHO NM
87124-4733
US

IV. Provider business mailing address

1105 GOLF COURSE RD SE BLD A
RIO RANCHO NM
87124-4733
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-3190
  • Fax: 505-994-2053
Mailing address:
  • Phone: 505-891-3190
  • Fax: 505-994-2053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD1560
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: