Provider Demographics
NPI:1588730634
Name:MONTGOMERY, MARC LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:LOUIS
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4599 MCDONALD DRIVE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2147
Mailing Address - Country:US
Mailing Address - Phone:651-351-0406
Mailing Address - Fax:
Practice Address - Street 1:8380 CITY CENTRE DR STE 130
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5304
Practice Address - Country:US
Practice Address - Phone:651-738-1880
Practice Address - Fax:651-730-7172
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND99831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice