Provider Demographics
NPI:1255441002
Name:MONTGOMERY, JOHN (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18924 FREEPORT DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356
Mailing Address - Country:US
Mailing Address - Phone:936-582-4396
Mailing Address - Fax:936-582-4311
Practice Address - Street 1:18924 FREEPORT DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356
Practice Address - Country:US
Practice Address - Phone:936-582-4396
Practice Address - Fax:936-582-4311
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD84D226OtherBLUE CROSS BLUE SHIELD OF