Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | IL |
NPI | 1134100910 |
---|---|
Provider Name | Dr. Angela Marie Montellano |
First Address | Barksdale Afb, LA 71110-2037 |
Second Address | Barksdale Afb, LA 71110-2486 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2005 |
Last Update Date | 26/11/2007 |