Provider Demographics
NPI:1063863272
Name:MONTGOMERY, JESSICA L (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2983
Mailing Address - Country:US
Mailing Address - Phone:229-888-6559
Mailing Address - Fax:229-436-4107
Practice Address - Street 1:118 E GIRARD AVE
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2712
Practice Address - Country:US
Practice Address - Phone:678-246-5174
Practice Address - Fax:678-901-3336
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO15220122300000X
GADN0152201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist