Provider Demographics
NPI:1164572665
Name:MONTGOMERY, MONTE' ERELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONTE'
Middle Name:ERELL
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 CLOVER LEAF LOOP
Mailing Address - Street 2:115 N. STATE ST.
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-8540
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:97479-0719
Practice Address - Country:US
Practice Address - Phone:541-459-4612
Practice Address - Fax:541-459-4911
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice