Provider Demographics
NPI:1619354693
Name:MONTGOMERY COMPREHENSIVE DENTAL CENTER
Entity Type:Organization
Organization Name:MONTGOMERY COMPREHENSIVE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-539-3636
Mailing Address - Street 1:0951 LONESTAR PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-0951
Mailing Address - Country:US
Mailing Address - Phone:936-230-5445
Mailing Address - Fax:
Practice Address - Street 1:2210 N FRAZIER ST
Practice Address - Street 2:SUITE #120
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77303-1780
Practice Address - Country:US
Practice Address - Phone:936-539-3636
Practice Address - Fax:936-539-3639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16499302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization