Healthcare Provider Details

I. General information

NPI: 1134648249
Provider Name (Legal Business Name): MICHAEL MONTGOMEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8055 W MANCHESTER AVE STE 500
PLAYA DEL REY CA
90293-7965
US

IV. Provider business mailing address

8055 W MANCHESTER AVE STE 500
PLAYA DEL REY CA
90293-7965
US

V. Phone/Fax

Practice location:
  • Phone: 310-821-0992
  • Fax: 310-821-9027
Mailing address:
  • Phone: 310-821-0992
  • Fax: 310-821-9027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number29383
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number29383
License Number StateCA

VIII. Authorized Official

Name: MICHAEL MONTGOMERY
Title or Position: OWNER
Credential: DDS
Phone: 310-821-0992