Provider Demographics
NPI:1801980180
Name:MARVEL, MONTGOMERY W (DDS)
Entity type:Individual
Prefix:DR
First Name:MONTGOMERY
Middle Name:W
Last Name:MARVEL
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 1:829 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-3236
Mailing Address - Country:US
Mailing Address - Phone:765-342-7090
Mailing Address - Fax:765-342-6703
Practice Address - Street 1:829 PLAZA DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-3236
Practice Address - Country:US
Practice Address - Phone:765-342-7090
Practice Address - Fax:765-342-6703
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009250A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000381014OtherBLUE CROSS PIN #
IN000000381014OtherBLUE CROSS PIN #