Healthcare Provider Details

I. General information

NPI: 1043300262
Provider Name (Legal Business Name): ORTHODONTIC CARE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 GLAZIER AVE. S.
APPLE VALLEY MN
55124
US

IV. Provider business mailing address

14605 GLAZIER AVE S
APPLE VALLEY MN
55124
US

V. Phone/Fax

Practice location:
  • Phone: 952-432-1103
  • Fax: 952-891-8678
Mailing address:
  • Phone: 952-432-1103
  • Fax: 952-891-8678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY JAMES MONTGOMERY
Title or Position: PRESIDENT
Credential: DDS
Phone: 952-432-1103