MEDICARE: DR. MAX PAUL MONCAYO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0106X	Oral and Maxillofacial Pathology Dentistry	DD5229	NM
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	53926	CA
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	00205024	CO

General Provider Information

NPI Number	:	1588636310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAX PAUL MONCAYO DDS

Provider Business Mailing Address
First Line	:	3515 SAN JOAQUIN PLZ
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-5971
Country	:	US
Telephone Number	:	909-908-9660
Fax Number	:

Provider Business Practice Location Address
First Line	:	881 ALMA REAL DR STE T4
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3743
Country	:	US
Telephone Number	:	310-459-0014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	04/22/2022

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