Healthcare Provider Details

I. General information

NPI: 1366333882
Provider Name (Legal Business Name): AYA MONTASOR IDREES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2025
Last Update Date: 07/12/2025
Certification Date: 07/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19919 SONTERRA LN
RICHMOND TX
77407-1917
US

IV. Provider business mailing address

19919 SONTERRA LN
RICHMOND TX
77407-1917
US

V. Phone/Fax

Practice location:
  • Phone: 916-849-4232
  • Fax:
Mailing address:
  • Phone: 916-849-4232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41644
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: