Provider Demographics
NPI:1679674931
Name:WATSON-MONTGOMERY, MELANIE ROSE (DDS)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ROSE
Last Name:WATSON-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 1:3330 W 177TH ST
Mailing Address - Street 2:UNIT 1-G
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2186
Mailing Address - Country:US
Mailing Address - Phone:708-798-7400
Mailing Address - Fax:708-798-7503
Practice Address - Street 1:3330 W 177TH ST
Practice Address - Street 2:UNIT 1-G
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2186
Practice Address - Country:US
Practice Address - Phone:708-798-7400
Practice Address - Fax:708-798-7503
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL432080709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL432080709Medicaid