=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245309160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YAMILETH MONTOYA PATE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2618 SE J ST SUITE 6
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-254-8111
-----------------------------------------------------
Fax | 475-254-8112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2618 SE J ST SUITE 6
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-254-8111
-----------------------------------------------------
Fax | 475-254-8112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3302
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------