Provider Demographics
NPI:1184851354
Name:MONTGOMERY, MARSHALL BRADY (DMD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:BRADY
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 1:874 PURCHASE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-6232
Mailing Address - Country:US
Mailing Address - Phone:508-984-7031
Mailing Address - Fax:508-984-7034
Practice Address - Street 1:850 PURCHASE ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6232
Practice Address - Country:US
Practice Address - Phone:508-992-6553
Practice Address - Fax:508-999-5457
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855260122300000X
RIDEN03099122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087629AMedicaid