Provider Demographics
NPI:1750695417
Name:MONTROSE, JEREMY DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DAVID
Last Name:MONTROSE
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 1:1750 TELSTAR DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1052
Mailing Address - Country:US
Mailing Address - Phone:719-400-7540
Mailing Address - Fax:
Practice Address - Street 1:1750 TELSTAR DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1052
Practice Address - Country:US
Practice Address - Phone:719-400-7540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9472122300000X
CODEN002034661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist