Provider Demographics
NPI:1386850733
Name:MONTGOMERY, ANGELA (DMD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:MONTGOMERY
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:WEIR
Mailing Address - State:MS
Mailing Address - Zip Code:39772
Mailing Address - Country:US
Mailing Address - Phone:662-547-5392
Mailing Address - Fax:662-547-5107
Practice Address - Street 1:392 FRONT ST
Practice Address - Street 2:
Practice Address - City:WEIR
Practice Address - State:MS
Practice Address - Zip Code:39772
Practice Address - Country:US
Practice Address - Phone:662-547-5392
Practice Address - Fax:662-547-5107
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2686921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660009Medicaid