Provider Demographics
NPI:1134648249
Name:MICHAEL MONTGOMEY
Entity Type:Organization
Organization Name:MICHAEL MONTGOMEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-821-0992
Mailing Address - Street 1:8055 W MANCHESTER AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7965
Mailing Address - Country:US
Mailing Address - Phone:310-821-0992
Mailing Address - Fax:310-821-9027
Practice Address - Street 1:8055 W MANCHESTER AVE STE 500
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-7965
Practice Address - Country:US
Practice Address - Phone:310-821-0992
Practice Address - Fax:310-821-9027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293831223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty