Provider Demographics
NPI:1710624861
Name:JEFFREY D. MONTGOMERY, DDS, PC
Entity Type:Organization
Organization Name:JEFFREY D. MONTGOMERY, DDS, PC
Other - Org Name:JEFF MONTGOMERY, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:VICENTA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:116 RAVINE ST STE 10
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-3311
Mailing Address - Country:US
Mailing Address - Phone:276-386-6162
Mailing Address - Fax:
Practice Address - Street 1:116 RAVINE ST STE 101
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-3312
Practice Address - Country:US
Practice Address - Phone:276-386-6162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-18
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty