Provider Demographics
NPI:1255575502
Name:MONTGOMERY, TATE (DDS)
Entity type:Individual
Prefix:
First Name:TATE
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:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74067-0030
Mailing Address - Country:US
Mailing Address - Phone:918-200-9610
Mailing Address - Fax:913-904-1353
Practice Address - Street 1:3824 S BOULEVARD STE 110
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5779
Practice Address - Country:US
Practice Address - Phone:918-200-9610
Practice Address - Fax:913-904-1353
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6231122300000X, 1223D0004X
CA58243122300000X
KS60643122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program