Provider Demographics
NPI:1558424309
Name:MONTGOMERY, MARK WOODROW (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WOODROW
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 COMMERCIAL ST SE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-391-2848
Mailing Address - Fax:503-391-0402
Practice Address - Street 1:925 COMMERCIAL ST SE
Practice Address - Street 2:SUITE 240
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-391-2848
Practice Address - Fax:503-391-0402
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR56781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice