Provider Demographics
NPI:1477665115
Name:MONTGOMERY, RONALD DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DALE
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6846 COOLEY LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-4109
Mailing Address - Country:US
Mailing Address - Phone:248-363-1543
Mailing Address - Fax:
Practice Address - Street 1:6846 COOLEY LAKE ROAD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-4109
Practice Address - Country:US
Practice Address - Phone:248-363-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1754078Medicaid
MI950F35099OtherBLUE CROSS
0F35099Medicare ID - Type Unspecified