Provider Demographics
NPI:1508860933
Name:MONTGOMERY, ANDREA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NW 67TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-4202
Mailing Address - Country:US
Mailing Address - Phone:580-536-3313
Mailing Address - Fax:580-536-2011
Practice Address - Street 1:725 NW 67TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-4202
Practice Address - Country:US
Practice Address - Phone:580-536-3313
Practice Address - Fax:580-536-2011
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200035620AMedicaid