Provider Demographics
NPI:1386798049
Name:MONTGOMERY, TIMOTHY J (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
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 1:14605 GLAZIER AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7545
Mailing Address - Country:US
Mailing Address - Phone:952-432-1103
Mailing Address - Fax:
Practice Address - Street 1:16570 W 78TH ST
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55346-4308
Practice Address - Country:US
Practice Address - Phone:952-937-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN84661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics