Provider Demographics
NPI:1477633196
Name:MONTGOMERY, MICHAEL CLINTON (DMD,PC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CLINTON
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DMD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 BARCLAY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-4621
Mailing Address - Country:US
Mailing Address - Phone:706-342-1242
Mailing Address - Fax:
Practice Address - Street 1:1040 BARCLAY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-4621
Practice Address - Country:US
Practice Address - Phone:706-342-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO103471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice