Provider Demographics
NPI:1891349874
Name:MONTGOMERY, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15660 DALLAS PKWY STE 925
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-3323
Mailing Address - Country:US
Mailing Address - Phone:214-702-0720
Mailing Address - Fax:
Practice Address - Street 1:6801 NW 39TH EXPY STE A
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2501
Practice Address - Country:US
Practice Address - Phone:405-787-1946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice