Provider Demographics
NPI:1821361940
Name:CHARLES E. MONTAGUE,III,D.M.D.,P.S.C.
Entity Type:Organization
Organization Name:CHARLES E. MONTAGUE,III,D.M.D.,P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:MONTAGUE
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-329-0919
Mailing Address - Street 1:1330 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7550
Mailing Address - Country:US
Mailing Address - Phone:606-329-0919
Mailing Address - Fax:
Practice Address - Street 1:1330 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7550
Practice Address - Country:US
Practice Address - Phone:606-329-0919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty