Healthcare Provider Details

I. General information

NPI: 1376996512
Provider Name (Legal Business Name): MONTGOMERY DENTAL ARTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 CHANTILLY PARKWAY
MONTGOMERY AL
36117
US

IV. Provider business mailing address

10650 CHANTILLY PKWY
MONTGOMERY AL
36117-7582
US

V. Phone/Fax

Practice location:
  • Phone: 334-398-2907
  • Fax: 678-840-3982
Mailing address:
  • Phone: 334-356-0228
  • Fax: 334-356-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DOMINIQUE A SHAMBURGER JR.
Title or Position: MBR
Credential: DDS
Phone: 334-356-0228