Provider Demographics
NPI:1063081115
Name:MONTAG, GRACE (DDS)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:MONTAG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:E
Other - Last Name:DICKERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5000 BLACKMORE RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3345
Mailing Address - Country:US
Mailing Address - Phone:307-233-6000
Mailing Address - Fax:307-233-6089
Practice Address - Street 1:5000 BLACKMORE RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3345
Practice Address - Country:US
Practice Address - Phone:307-233-6000
Practice Address - Fax:307-233-6089
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15881223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health