Provider Demographics
NPI:1043456403
Name:SUTHERLIN DENTAL
Entity Type:Organization
Organization Name:SUTHERLIN DENTAL
Other - Org Name:MONTE' E. MONTGOMERY DDS, PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTE'
Authorized Official - Middle Name:ERELL
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-459-4612
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-0719
Mailing Address - Country:US
Mailing Address - Phone:541-459-4612
Mailing Address - Fax:541-459-4911
Practice Address - Street 1:115 N STATE ST
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-9807
Practice Address - Country:US
Practice Address - Phone:541-459-4612
Practice Address - Fax:541-459-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6919261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental