Provider Demographics
NPI:1730230574
Name:MONTAZEM, ALEX (DMD)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:MONTAZEM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 E MAIN ST STE 108
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2912
Mailing Address - Country:US
Mailing Address - Phone:631-265-9700
Mailing Address - Fax:631-265-9703
Practice Address - Street 1:285 E MAIN ST STE 108
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2912
Practice Address - Country:US
Practice Address - Phone:631-265-9700
Practice Address - Fax:631-265-9703
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0427301223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1364282OtherUNITED HEALTHCARE
P3492579OtherOXFORD
116561OtherCIGNA DMO
NY0565561OtherGHI MEDICAL
NY522421POtherHIP
D99121OtherEMPIRE BCBS