Provider Demographics
NPI:1043413024
Name:MONTGOMERY, MARK N (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:N
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:32241 CROWN VALLEY PARKWAY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MONARCH BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92629
Mailing Address - Country:US
Mailing Address - Phone:949-493-3333
Mailing Address - Fax:949-493-2057
Practice Address - Street 1:32241 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:MONARCH BEACH
Practice Address - State:CA
Practice Address - Zip Code:92629-3346
Practice Address - Country:US
Practice Address - Phone:949-493-3333
Practice Address - Fax:949-493-2057
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA316731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice