Provider Demographics
NPI:1457807547
Name:MONTGOMERY, GREGORY (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
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 1:6810 MENAUL BLVD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6810 MENAUL BLVD. NE SUITE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-872-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4565122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist