Healthcare Provider Details

I. General information

NPI: 1831685452
Provider Name (Legal Business Name): EDGARDO MONTES ZETINO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COMMERCE LN
CANTON NY
13617-3739
US

IV. Provider business mailing address

PO BOX 3835
SEATTLE WA
98124-3835
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-8191
  • Fax:
Mailing address:
  • Phone: 206-548-3114
  • Fax: 206-762-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number063860
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRR60865273
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: