Provider Demographics
NPI:1396255097
Name:GONZALEZ MONTOYA, EDWIN (OMFS)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:GONZALEZ MONTOYA
Suffix:
Gender:M
Credentials:OMFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 ELMIRA AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-7724
Mailing Address - Country:US
Mailing Address - Phone:787-587-9675
Mailing Address - Fax:
Practice Address - Street 1:6585 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2542
Practice Address - Country:US
Practice Address - Phone:787-587-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031410122300000X, 1223G0001X
IL0210028491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice